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Employee Name
*
First
Last
What is the primary reason for requesting a transition to biweekly sessions?
*
Scheduling constraints
Financial considerations
Clinical progress / decreased need
Other
If you choose "other", please explain:
Treatment Phase
*
Assessment (8–12 sessions)
Active treatment
Maintenance
Pre-termination
Has the client completed at least 3–4 treatment review cycles (9–12 months)?
*
Yes
No
Has progress been consistently tracked across reviews?
*
Yes
No
Client's Ability to Utilize Skills?
*
Limited
Moderate
Strong
Is Biweekly Appropriate?
*
Yes
No
Please describe the reason(s) why biweekly appropriate
*
Plan for Biweekly sessions?
*
Temporary biweekly
Toward termination (60–90 days)
Continue biweekly
Scheduling plan:
*
Fixed biweekly
Client reaches out weekly
Clinician/Supervisor Decision
*
Continue weekly
Transition to biweekly
As-needed
Discharge/referral
Name been Client's
Documentation/Chart note completed?
*
Yes
No
Additional Notes
Signature
*
Clear Signature
Submit
