Confirmation Page

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The following information is what was submitted on the Espyr Closed Case Form. We recommend that you save this email for any future correspondence.

Entry ID: {entry_id}
Authorization Number: {Authorizaton Number:72}
Counselor: {Counselor:1}
Client DOB: {Client Date of Birth:71}
Attended EAP session? {Attended EAP session?:36}

Presenting Problem: {Presenting Problem:45}

Assessed Problem: {Assessed Problem:44}

Was Client helped by your service? {Was client helped by your service?:43}

Impact of problem on Job Performance: {Impact of problem on Job Performance::11}

ICD 10#: {ICD 10#:75}

Description: {Description:76}

ICD 10#: {ICD 10 #:77}

Description: {Description:78}

ICD 10#: {ICD 10#:79}

Description: {Description:80}

ICD 10#: {ICD 10#:81}

Description: {Description:82}

ICD 10#: {ICD 10#:83}

Description: {Description:84}

Referrals Made: {Referrals Made: (check all that apply):87}

Axis I: {Axis I:13}

Axis II: {Axis II:14}

Axis III: {Axis III:15}

Axis IV: {Axis IV:16}

Axis V: {Axis V:17}

Date Seen: {Date Seen 1:53}

Date Seen: {Date Seen 2:54}

Date Seen: {Date Seen 3:55}

Date Seen: {Date Seen 4:56}

Date Seen: {Date Seen 5:57}

Date Seen: {Date Seen 6:58}

Date Seen: {Date Seen 7:59}

Date Seen: {Date Seen 8:60}

List additional dates seen below (* next to one indicates no shows/unexcused late cancellation): {List additional dates seen below. Put * next to no shows / unexcused late cancellations:70}

Outcome: {Outcome:35}

Referral Made: {Referrals Made (check all that apply):22}

If referred, specify facility or clinician name: {If referred, specify facility or clinician name:34}

Reason for Referral: {Reason for Referral:24}

Did Client accept the referral: {Did client accept the referral?:42}

If no, please explain: {If no, please explain:26}

Describe termination and disposition if problem was unresolved and client not referred: {Describe termination and disposition if problem was unresolved and client not referred:31}

Follow-up call made: {Follow up call made?:40}

Date of first follow- up call: {Date of first follow-up call:29}

Date of second follow-up call: {Date of second follow-up call:30}

If follow-up call not made, please provide reason: {If follow-up call not made, please provide reason:39}

Date Submitted: {Date Submitted:41}

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