Session Extension Request Form

Please complete this form to request up to an additional 8 sessions for your client.

Provider first name

Provider last name

Provider email address

Provider phone number

Client name

Full name of the client for whom you are requesting additional sessions

Client ID or case number

Enter the unique identifier or case number for this client

Number of additional sessions requested

Enter the number of additional sessions needed (maximum 8 sessions)

Progress report

Provide a detailed progress report including current status, improvements observed, and goals achieved

Justification for additional sessions

Explain why additional sessions are necessary and how they will benefit the client's treatment plan

Additional services needed

Select all additional services that may be required during the extended sessions

Treatment goals for extended sessions

Outline specific, measurable goals you plan to achieve during the additional sessions

Requested start date for additional sessions

When would you like the additional sessions to begin?

Provider signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Please provide your digital signature to certify the accuracy of this request