OCR Session Note - Forensic Evaluation Service Center

Your Name *

You should choose your name here.

What type of service are you providing?

OCR SESSION direct service defendant
OCR ASSESSMENT or case-related Admin
OCR Supervision Session
OCR broader administrative activity
OCR instructor training session

Who is providing ADMIN or SUPERVISION service?

Erin
Jenny
Joy
Natalie

LAS - FIR of the Client being served *

If this is not about a specific client (you checked admin above) - type "PROGRAM" This is for when it's about program building or reporting or meeting with providers, etc.

Describe type of Session:

Regularly Scheduled education- completed session
Maintenance Session (regularly scheduled)
Scheduled but Failed Session

Describe type of Admin of Doctoral Level Session

INTAKE interview (doctoral level)
30-day update or case closure letter
Supervision or Training
final full assessment
Monthly report to the state

Which County's Court? *

This is for billing. We have a grant to pay for the Adult Courts assigned to our catchment area. Juvenile Courts are FEE for SERVICE.

If Juvenile Court, which county?

SERVICE DATE *

IF the session didn't last more than 5 minutes, check here

Session DID NOT last more than 5 minutes

IS THIS A CORRECTED/Duplicate Note?

YES
No, it's the original entry

Length of session (in minutes) if longer than 5 minutes. *

In no less than 15-minute increments (please) 90, 60 (minutes) 45, 30, 0 (no show, but alerted us ahead of time)

Did the instructor travel more than 20 minutes each way for the session?

Yes, bill for travel
No, minimal travel was required

Here we are documenting travel for billing.

Why didn't session occur?

Cancelled Ahead of Time
NO SHOW - no notice - or really late
Terminated Session early-on*
Instructor had to reschedule

Tracking Billing and Attendance information here - so this is if there was NO appreciable session (less than 5 minutes)

Are there going to be CHARGES for an Interpreter?

There was a professional INTERPRETER involved
No.

Effort in session *

Excellent
Good
Fair
Poor
N/A

How concerned are you about signs of decompensation after meeting with this defendant, today?

Selected Value: 0

0 is no concern. 15 is concerned enough that you are going to contact the treatment provider. 20 means we will contact the court about this concern. 30 is concerned enough to PINK SLIP the individual. All actions must be documented in the chart.

What areas of risk of decompensastion* are you concerned about after this session (check as many as you've identified)? *

NONE, the client is compliant and coping adequately
psychiatric medication, treatment compliance
abstinence from intoxicants
decrease in self-care, hygiene, sleep
attending work, meetings, other structured obligations or events
changes in mood regulation, cognitions, affect (speech, affect, bizarre behavior or thoughts)
OTHER, or Not a session - see PROGRESS NOTE

Progress toward restoration *

N/A - none
Maintenance
Excellent
Good
Fair
Poor

Maintenance Session -

Continues to Maintain/Improve
Serious Deterioration

What slides or workbook materials did you get through?

This is so the next instructor can track where you are.

Describe defendant's mental status, if known.

Orientation, engagement, anxiety-management, emotional stability.

Progress/Training Note *

Describe the service you provided so you know enough about it to start the next session. Topics, progress or obstacles, interruptions, or next steps (ready to go to court, opined incomp and not restorable).

Training - Your Name

Type your name in the box so we can show you participated in the training.