ࡱ> surq` FVbjbjqPqP y^:: ]  8\4 L l@"@"@"@"d%D&D'PKKKKKKK$#NhP~Ki '$|`%''K@"@"GLP*P*P*'dV@" @"KP*'KP*P*lEl" H@" "@'dF*lIL]L0LG Q\( QTH Q H''P*'''''KK)^'''L''''    A N N E X A PROGRAM COMMITMENTS OUTPATIENT SERVICES  NAME OF AGENCY:  FORMTEXT       CONTRACT NUMBER:  FORMTEXT      CONTRACT TERM:  FORMTEXT       TO  FORMTEXT        BUDGET MATRIX CODE: BUDGET MODIFICATION NO: 18-19-20 (0 = Original)  FORMTEXT        1.  FORMTEXT      Number of face-to-face contacts clients will have with staff on-site. 2.  FORMTEXT       Number of face-to-face contacts clients will have with staff off-site. 3. The following is a breakdown by MODALITY of the number of face-to-face client contacts with staff (both on-site and off-site): TOTAL # OF STAFF FACE-TO-FACE CONTACTS TO BE PROVIDED: A.Individual TherapyA. FORMTEXT      B.Group TherapyB. FORMTEXT      C.Family TherapyC. FORMTEXT      D.Medication MaintenanceD. FORMTEXT      E.Intake/Clinical Assessment/Treatment PlanningE. FORMTEXT      F.Outreach to Individuals Residing in Independent LivingF. FORMTEXT      G.Outreach to Individuals Residing in Boarding HomesG. FORMTEXT      H.Outreach to Individuals Residing in Nursing HomesH. FORMTEXT      I.All Other Contacts Not Classified Above: Specify:  FORMTEXT      I. FORMTEXT       Total Number of Contacts (Sum of lines 3A through 3I) (   =SUM(Above) 0 4.  FORMTEXT       Units of service will be provided. (Sum of lines 1 and 2). 5.  FORMTEXT       Other client related commitments. (Please attach addendum). OUTPATIENT SERVICES  FACE-TO-FACE CONTACTS: Individual Therapy: 1 contact is 30 continuous minutes of face-to-face with the consumer. 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Do not count excess over Medicaid maximum group size. Family Therapy: 1 contact is 30 continuous minutes of face-to-face with the consumer. Do not count each family member. Medication Monitoring: 1 contact is 15 continuous minutes of face-to-face with the consumer. Intake/Clinical Assessment/Treatment Planning: 1 contact is 30 continuous minutes of face-to-face contact with the consumer. Outreach and Other: 1 contact is 15 continuous minutes of face-to-face with the consumer. For the therapies, please note that the face-to-face time can include up to 5 minutes per 30 minute session for the completion of progress notes, limited to a maximum of 10 minutes for a 90 minute session (3 QCMR units).     6/07 Page 1 of 1 ANNEX A: Outpatient Services 6/07 Page 1 of 1 ANNEX A: Outpatient Services A set of counseling interventions provided by trained clinicians to clients living in the community who require non-immediate care that can be delivered on a scheduled basis. 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