Skip to content

Grand Journey Behavioral Health Solutions

  • GJS FormsExpand
    • TOOLS
    • HR DOCUMENTSExpand
      • CONTRACTOR INVOICE
      • EMPLOYMENT APPLICATION
      • SERVICE TICKET
      • STAFF TRAINING
    • OTHER DOCUMENTSExpand
      • CLIENT SATISFACTION SURVEY
      • RELEASES OF INFORMATION TO GJBHS
      • STAKEHOLDER SATISFACTION SURVEY
Grand Journey Behavioral Health Solutions

SERVICE TICKET

The dates and service codes provided will be cross-referenced with notes submitted in the EMR. Any information provided that does not have documentation completed, will not be compensated. Once documentation is submitted, compensation will be released during the next pay cycle. Be sure to keep a copy of this service ticket for your reference. By submitting this document, you attest that the information provided is accurate and true to the best of your abilities. Any information that is identified as misleading or untrue will be investigated and prosecuted to the fullest extent.

Step 1 of 5

20%
Staff Name:(Required)

PRP

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

THERAPY

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name

MEDICATION MANAGEMENT

MM slash DD slash YYYY
Consumer Name
IF THERAPY WAS HELD IN THIS SESSION

MM slash DD slash YYYY
Consumer Name

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:

MM slash DD slash YYYY
Consumer Name:
My signature verifies that the information provided is true to the best of my knowledge.

© 2024 Grand Journey Behavioral Health Solutions - WordPress Theme by Kadence WP

  • GJS Forms
    • TOOLS
    • HR DOCUMENTS
      • CONTRACTOR INVOICE
      • EMPLOYMENT APPLICATION
      • SERVICE TICKET
      • STAFF TRAINING
    • OTHER DOCUMENTS
      • CLIENT SATISFACTION SURVEY
      • RELEASES OF INFORMATION TO GJBHS
      • STAKEHOLDER SATISFACTION SURVEY