
DISTRIBUTION: Original – PSU Record (Referrals/Screening/Contacts Section)
DEPARTMENT OF CORRECTIONS
Division of Adult Institutions
DOC-3658 (8/2011)
MENTAL HEALTH GROUP
PROGRESS NOTES
PATIENT NAME (Last, First, MI)
ADDITIONAL COMMENTS/OBSERVATIONS
ADDITIONAL COMMENTS/OBSERVATIONS
ADDITIONAL COMMENTS/OBSERVATIONS
ADDITIONAL COMMENTS/OBSERVATIONS
PRINT or TYPE SUPERVISOR NAME (if necessary)
SUPERVISOR SIGNATURE (if necessary)