Daily Treatment Log - Western District of Texas

Attachment J.6

DAILY TREATMENT LOG

Print Form

COMPLETE ONE FORM PER CLIENT PER MONTH

Client Name:

Date

PACTS #:

Client's Signature/Initials

Time In

Purpose of Visit

Month / Year:

Co-Pay

Collected

Time Out

Client's

Initials

Vendor's

Initials

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download