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Office of Mental Health

EBTDC Tracking Form

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This form is to help you keep track of your work with children and families using the EBTDC protocols (DBD treatment). It is a worksheet. Keeping this form up to date will help you complete the EBTDC Monthly Reporting Form. Do not submit this form to OMH.

Name: Day and Time of Calls:
Operating Certificate: Date of 1st Call:
Clinician ID: Consultant:
Call Group: Dial In:
Calls: Dates Dates Dates Presented Number Reported
September        
October        
November        
December        
January        
February        
March        
April        
May        
June        
July        
August        
Cases
Initials          
Child ID          
Treatment CP &/or PM          
Assessment Dates          
Session Dates          
Treatment Status          
Pre-SNAP Score          
Date Pre-SNAP          
Goals Met          
Completion
Post-SNAP Score          
Date Post-SNAP          
# Treatment Sessions          
Month Reported