School-Based Medicaid Service Note (Psychological Counseling)

(This is a concise, school-based Medicaid progress/service note template. Do not include detailed psychotherapy process content or verbatim dialogue. Provide enough clinical context to support medical necessity.)

(If any required billing elements — date of service, student identifiers, provider identity, service time/units, or signature — are missing, flag the note as "Incomplete — Missing Required Elements" and do not submit for billing. Corrections to finalized notes must be completed as dated addenda, not overwrites.)

Date of Service: [Date]

Student Name: [Full name]

DOB: [MM/DD/YYYY]

Medicaid ID: [ID]

School/Grade: [School name, grade]

Provider: [Name, credentials, NPI if required by state]

Service Setting: [School name and location]

Service Type: [individual / group]; [in-person / telehealth]

Participants: Student present: [yes / no]; Others present: [roles only, or "none"]

IEP/Authorization: [IEP goal reference or treatment plan ID; "non-IEP pathway" if using expanded services]

Service Time and Units

(Capture only face-to-face/direct service time. Exclude travel, documentation, or care coordination time.)

Start Time: [HH:MM]

End Time: [HH:MM]

Direct Service Minutes: [Minutes]

Units Billed: [Number and unit definition per state policy]

(If the student was not seen due to no-show or cancellation, replace this and all remaining clinical sections with: "Student not seen — [reason]. No billable service provided.")

Session Focus and Interventions

[Presenting concern or counseling focus and its linkage to IEP goal(s) or treatment plan] (State in 1–2 sentences.)

[Interventions delivered with brief, behaviorally anchored descriptions—e.g., skills coaching, relaxation training, problem-solving practice, psychoeducation, crisis intervention. Note specific skills or tools practiced when relevant.]

(For group sessions, include session theme/activity and this student's participation level. Do not identify other students.)

Response and Progress

Engagement: [attentive / cooperative / avoidant / dysregulated / other] (Include brief mental status observations only if materially relevant.)

Response to Interventions: [Observable response and functional impact]

Progress: [improving / stable / worsening / barrier identified] (Note any barrier briefly.)

(Use direct quotes sparingly—only for safety statements, refusal of care, or key functional claims.)

Safety Assessment

(Include this section only when safety concerns are present, suspected, or routine screening is performed. Otherwise omit entirely.)

Assessment: [SI/HI/self-harm assessed: yes / no; results] (If screening expected but not done, state "not assessed" with reason.)

Risk Formulation: [Risk level and relevant protective factors]

Actions Taken: [Safety plan created/updated, guardian notified, mandated report filed, crisis protocol activated, referral made—include who was contacted and when]

Plan

Next Session: [Date or frequency]

Homework/Practice: [Skill practice or assignment]

Coordination/Referrals: [Pending coordination, responsible party, and timeline] (Include only if applicable.)

Disposition: [Continuing services / modifying plan / closing services] (If closing, document reason and aftercare plan.)

Provider Signature: [Handwritten or electronic signature]

Date/Time Signed: [MM/DD/YYYY HH:MM]

Credentials: [Credentials/license]

Supervisor Co-Signature: [Signature] (Include only if required by state supervision rules.)