McWilliams Center for Counseling, Inc.

Community Support Office – 438 E Garrison Blvd, Suite B - Gastonia, NC 28054 - 704-868-7001 704-868-7848 (FAX)
Form #3
NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Jaylen Johnson 1) Purpose of Contact;

1/9/2001 2) Description of Intervention/Activity;
946-80-9578-T 3) Effectiveness of the Intervention/Activity per Client;
239872 (*Other clients shall not be personally identified in the
note.)
Skill Building Activities Training of Caregiver
Date: _01/16/08 Therapeutic Mentoring Behavior & Anger Mgt.
Techniques Assessing Linking
Time:1:00 to 5:45 Hrs: 4.75 Coordinating Informing
Direct Indirect - Billable Non billable
Service Code: H0036HA
H0036HA (CSC) H0036HB (CSA) H2015HT (CST)
H0036HQ (CSG) H2022 (In-home)
Service Location: Community T1023 (DA) H0004 (Ind. outpatient) H0004 HR (Fam
w/ patient) H0004 HS (Fam w/out patient)

Goal #: Jaylen will work on increasing compliance to rules, directions and expectations in the school, home
and community setting. Jaylen will comply with requests and expectations from 2xs weekly to 5xs weekly.
I: QP assessed consumer's needs in services as evidenced by reviewing the consumer's chart. QP reviewed the consumer's
complete Person Centered Plan and determined that the consumer would benefit from AP/PP interventions through Community
Support Services in order to assist him with meeting his goals, especially with being able to accept responsibility for his actions and
communicating effectively with adults. QP also determined that the consumer would benefit from outpatient therapy services in order
to assist him with being able to work toward learning how to appropriately express himself rather than avoiding expressing his feelings
and lashing out at others. QP also determined that the consumer would continue to be linked with psychological testing in order to
clarify his diagnoses and to determine which services would be most beneficial for the consumer to meet his goals.
E: QP will continue to assess consumer's needs in services by reviewing his chart regularly and will coordinate any changes in
services as needed to ensure that he is able to work toward meeting the goals identified on his Person Centered Plan through
services provided. QP will also contact the consumer's AP/PP and consumer's guardian in order to schedule a treatment team
meeting as soon as possible so that the consumer may begin receiving AP/PP interventions through Community Support Services.
     

     

     

     

     

     

     
Staff Signature Client/ Legally Responsible Person Signature
Q’er Signature
     

     

     

     

     

     

SERVICE NOTE
 McWilliams Center for Counseling, Inc.
Community Support Office – 438 E Garrison Blvd, Suite B - Gastonia, NC 28054 - 704-868-7001 704-868-7848 (FAX)
Form #3
NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     
Staff Signature Client/ Legally Responsible Person Signature
Q’er Signature

SERVICE NOTE