REPS Provider Form 2024
Confidential & Complimentary Counseling
Please fill out and submit this form each time you send an invoice for a new client after their 5 REPS sessions.
Please only submit 1 form per client.
If this client needs additional sessions, please call (970) 846-8182 or email repssteamboat@gmail.com to discuss getting that approved.
This helps us to collect data so that we can continue to write grants and sustain this amazing program. Thank you for your hard work!
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Email *
Provider Name *
Invoice # or Account # *
When was your first session with this client? *
MM
/
DD
/
YYYY
How many sessions did this client utilize?
Clear selection
Please indicate if this client is a youth or an adult: *
Form of Meeting
Diagnosis (check all that apply)
Has the client improved within the 5 session time frame?
Clear selection
Has the client received the necessary support/tools to move forward in their healing journey?
Clear selection
Does the client have a safety plan?
Clear selection
Do you feel it would be beneficial for this client to have more sessions of counseling at this time?
Clear selection
Is there anything else you would like us to know? Additional Comments?
Submit
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