CONCERN® SERVICES 
BILLING/CLOSURE FORM 


**PLEASE COMPLETE ALL SECTIONS TO AVOID DELAYS IN PAYMENT** 

Client Name: Member ID #: 

Make Check Payable to: Tax ID #: 

Mailing Address: 

Email Address: 

List Dates of Service: 

Total # Sessions Delivered: 
Referral Log: 


EAP Services Only 

EAP Counseling & Collateral Referral 

EAP Assessment/Referral 

If Referral, to: 


CD Counselor 


Child Care 


Legal 


MH Residential 
CD Day Treatment 


Counselor/Social Worker 

Medical 

Psychiatrist 
CD Inpatient 


Educational/Vocational 

MH Day Treatment 

Psychologist 
CD Intensive Care 


Elder Care 

MH Inpatient 

Self Help 
CD Residential 


Financial 

MH Intensive Care 

MH Residential 

FREEDOM OF CHOICE AFFADAVIT: If a referral is necessary and client elected to remain with Affiliate 
therapist utilizing either their insurance or self pay, Affiliate attests that other options were discussed with client 
including advantages and disadvantages of each option and the cost of each option. 


PROBLEM TYPE (Choose One) WELL-BEING SUPPORT: Discussed 

CS1 


Workplace Problem CS6 


Other Life Stressors 


Proper Diet/Nutrition 
CS2 

Family CS7 

Relationship/Marital 

Importance of Sleep Hygiene 
CS3 

Health CS8 

Traumatic Event 

Need for Regular Exercise (MD approved) 
CS4 

Legal CS9 

Substance Abuse/Addiction 

Need for Preventive Screenings 
CS5 

Mental/Emotional CS99 

Nicotine Addiction 

Work/Life Resources on CONCERN website 

CLINICIAN RATING OF FUNCTIONAL IMPROVEMENT: 

(1=Very Serious problem, 2=Serious Problem, 3=Moderate Problem, 4=Slight Problem, 5=No Problem) 

Beginning Rating: 

1 

2 

3 

4 

5 Closing Rating: 

1 

2 

3 

4 

5 

CLOSING SUMMARY: 

Do you offer new client appointments after 5:00 pm? Yes No 
Affiliate Signature: 
CONCERN TC Signature: _________________ 
Date: 
Date: ___ 

BILLING DEPT USE ONLY: Date Posted: Posted By: _________________ Successful: Y N 

CONCERN® Services, 11121 Kenwood Road, Cincinnati, Ohio 45242 
Phone: 513-891-1627 or 800-642-9794 / Fax: 513-891-0838 
Website: www.concernservices.com/ Email: concern-as@trihealth.com