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Restorative Practice
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Diversity & Sensitivity Training
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Search for:
Home
Restorative Practice
Sports & Performance Psychology
Diversity & Sensitivity Training
Our Team
Request a Demo
Home
Restorative Practice
Sports & Performance Psychology
Diversity & Sensitivity Training
Our Team
Request a Demo
Session Tracker
admin@darcelny
2021-03-28T10:42:46+00:00
Provider Session Tracker
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Please Enter Your Provider Code
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Company
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BSE Global
Gotham FC
NY Jets
Other
Diagnoses Codes
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Adjustment Disorder, unspecified - F43.20
Adult sexual abuse by nonspouse or nonpartner, confirmed, initial encounter - T74.11XA
Adult sexual abuse by nonspouse or nonpartner, confirmed, subsequent encounter - T74.11XD
Adult sexual abuse by nonspouse or nonpartner, suspected, initial encounter - T76.11XA
Adult sexual abuse by nonspouse or nonpartner, suspected, subsequent encounter - T76.11XD
Agoraphobia - F40.00
ADHD, combined presentation - F90.2
ADHD, predominantly hyperactive/impulsive presentation - F90.1
ADHD, predominantly inattentive presentation - F90.0
Bipolar 1, current or most recent episode depressed, unspecified - F31.9
Bipolar 1, current or most recent episode hypomanic, unspecified - F31.9
Bipolar 1, current or most recent episode manic, unspecified - F31.9
Bipolar 2 disorder - F31.81
Borderline Personality Disorder - F60.3
Generalized Anxiety Disorder - F41.1
Major Depressive Disorder (MDD), recurrent episode, Unspecified - F33.9
MDD, recurrent episode, with psychotic features - F33.3
MDD, single episode, unspecified - F32.9
OCD - F42
Personal history (past history) of sexual abuse in childhood - Z62.810
PTSD - F43.10
Schizophrenia - F20.9
Social Anxiety Disorder (Social Phobia) - F40.10
Other
Please list Diagnoses
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Your Name
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First
Last
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Date of Service
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Date
Time
Name of Client
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First
Last
Date of Birth (Client)
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Address of Client
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Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
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Anguilla
Antarctica
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Argentina
Armenia
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Bouvet Island
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Jamaica
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Poland
Portugal
Puerto Rico
Qatar
Romania
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Rwanda
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Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
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Senegal
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United States of America
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Vanuatu
Vatican City State
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Virgin Islands (British)
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Wallis and Futuna
Western Sahara
Yemen
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Åland Islands
Country
Client's Company or Organization
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Service Time
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15 Minutes
30 Minutes
45 Minutes
60 Minutes
Type of Service
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Initial Individual
Individual Follow-Up
Initial Couple
Couple Follow-Up
Family Initial Evaluation
Family Follow-Up
Group Initial
Group Follow-Up
Anger Management
Leadership Coaching
Other
DSM-5 / DX
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Medications
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Known
Unknown
Other
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Today's Symptoms
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Mental Performance Issues?
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Yes
No
Please share performance issue
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Athlete?
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Yes
No
Which sport?
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Session Notes
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Psych Intervention (copy)
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Psych Impression
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Plan
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Next Appointment Scheduled?
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Next Appointment Details
Date
Time
Close this Case?
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Is a Referral Needed?
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Please Explain (Referral)
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