Treatment Plan Update | Improving Lives Counseling Services

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To Have Someone Else Complete the Treatment Plan Update for Your Client

Client First Name(Required)

First 5 Letters of Client's Last Name(Required)

Insurance ID(Required)

Insurance/Pay Source(Required)

Client Payment Amount(Required)

Please indicate how much the client pays per session so the therapist that is updating the treatment plan knows how much to charge the client.

CLIENT'S (or Guardian's) Current Phone Number(Required)

Client/Guardian Email Address(Required)

Date current tx plan expires(Required)

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Medicaid ID

Only clients with Medicaid as one of their payment sources need treatment plan updates. If the client does not have medicaid as a pay source, please complete a 6 month survey and submit a Simple Treatment Plan request using the CDC Request form.

Parent or Guardian's Name if the Client is a Minor

First Last

Clinician Email(Required)

Clinician Making Request(Required)

Full Name

Do you have a preference on who updates the treatment plan?(Required)

Yes

Name of clinician you would like to complete the treatment plan update(Required)

Treatment Plan Update Needed

To Have Someone Else Complete the Treatment Plan Update for Your Client