Authorized Treatment Progress/Status Report (External Stakeholders)

Report Date: [Report Date]

Reporting Period: [Start Date] – [End Date]

Patient Name: [Patient Name]

Date of Birth: [Date of Birth]

Program/Facility: [Name, address, phone]

Author: [Name, credentials, license]

Recipient: [Name, organization, role]

Purpose of Disclosure: [Brief statement of why report is being sent]

Authorization Basis: [Type of authorization or legal basis; date signed; expiration; scope summary including what categories are authorized; explicit exclusions; revocation status if applicable]

Confidentiality Notice: [SUD records / Non-SUD records]
(If SUD records: include 42 CFR Part 2 redisclosure prohibition notice. If Non-SUD: "Confidential health information disclosed for the stated purpose; further disclosure may be prohibited by law or authorization terms.")

Treatment Summary

[Admission/enrollment date]; [current status: active / discharged / stepped down / paused / transitioned]; [level of care and modality]. [High-level description of services provided during the reporting period]. [Diagnoses and medications if specifically authorized and necessary for stated purpose, otherwise state "not included per authorization scope"]

Attendance, Participation & Progress

Service/Modality	Scheduled	Attended	Missed (excused/unexcused)	Attendance Rate	Notes
[Service type]	[#]	[#]	[# / #]	[%]	[Brief objective note or N/A]

(If table format not appropriate, use narrative: "[# services scheduled; # attended; # missed (# excused / # unexcused); overall attendance rate #%]")

Participation/Engagement: [Objective, behaviorally anchored observations of engagement] (Use neutral language; avoid session content or psychotherapy-note material.)

Goals & Progress:

• [Goal 1]: [progressing / partial progress / maintained / not progressing / deferred]. [Objective indicators or milestones]. [Source: observed / patient-reported / collateral-reported / record-derived]
• [Goal 2]: [Status]. [Objective indicators]. [Source]
• [Standardized measure results if collected and authorized]: [Instrument, date, score, brief interpretation]

Toxicology: [Not collected / Not part of program / Not authorized for disclosure / Collection dates and general findings] (If included, note interpretive limitations: detection windows vary; potential for false positives/negatives; results do not indicate timing or amount.)

Safety & Recommendations

Safety/Risk Status: [Assessed / Not assessed this period]. [No acute safety concerns identified / Safety concern identified on date; actions taken] (Use minimal language; avoid detailed narratives unless essential to describe risk and actions taken.)

Clinical Recommendations:

• [Continue current level of care / Step up / Step down / Transition / Discharge] with [frequency/intensity] for [timeframe]
• [Referrals or adjunctive services if authorized]
• [Monitoring expectations]
• [Next status report timeframe if ongoing reporting expected]
• [Compliance with external requirements if requested: objective status only, e.g., "Attendance meets/does not meet program expectation of X%"] (Avoid legal conclusions, sanctions recommendations, or character assessments.)

Attestation: "I certify this summary is accurate to the best of my knowledge based on clinical encounters and program records for the reporting period stated."

Signature: [Signature]

Date Signed: [Date]

Credentials: [Credentials]

(This report is a limited summary prepared for the stated purpose and recipient. It is not the complete clinical record and should not be redisclosed except as permitted by applicable authorization and law. If any information is not available, not assessed, or excluded per authorization scope, state this explicitly rather than leaving blank.)