In-Person School Treatment Daily Tracking Form

Date of Report Entry*

Name of Treatment Provider*

Select or enter value

Name of Treatment Provider (not listed)

School/Treatment Location*

Select or enter value

Name of School/Treatment Location (not listed)

Treatment Overview Data

Date of Treatment Provided*

Total Number of Students Seen*

Number of Appointments Not Kept*

(missed appointments)

Number of students seen required to attend*

Number of students seen that were required to attend

Number of students who are voluntary participants*

Number of students seen that referred by staff*

Number of students seen for their initial visit*

Number of students seen for a follow up visit*

Number of Students Enrolled in MLMQ*

(enrolled during visit)

Number of Students Enrolled in the MaineQuitLink

students who are 18+ (enrolled during the visit)

Narrative*

**No identifying patient information included

Quotes

Enter any noteworthy quotes from students or staff members here:

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