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Prob. Form **

Today's Date: */**/**

Initial

TREATMENT SERVICES CONTRACT PROGRAM PLAN

Client Identifying Information

Client: Batchelor, Deshawn Evans PACTS #: 5058843

Address: **** **** *ountain Drive

Forest Park GA 30297

Pretrial/Post

Conviction:

Post Conviction

Officer: Ferguson, Brandon M. Client Phone: 404-***-**** Officer Phone: 404-***-**** DOB: 09/10/1989

Provider Information

Provider: Ascensa Health Procurement No: 113E-2023-0002 Provider Location: Ascensa Health Effective Date: 07/01/2023 Attn: Kyle McCranie;

ad1q0g@r.postjobfree.com

Termination Date:

Location Address: 139 Renaissance Parkway

Northeast

Atlanta GA 30308

Phone: 404-***-****

Fax: 404-***-****

Authorized Services

Your agency is authorized to provide the following services beginning on the plan effective date indicated above. Any services provided outside of those listed below and/or outside the Effective and Termination Dates of the Plan will not be authorized for payment. Services Ordered

Project Code Description Of Services Phase Frequency (Units) Interval Copay Amount

(per unit)

2011 Substance Abuse

Disorder Intake

Assessment Report

1.0 Per Plan $0.00

2020 Group Substance Abuse

Counseling

2.0 Weekly $0.00

Instructions to Provider Regarding Client Needs and Goals of Treatment Officer: Ferguson, Brandon M. Referral Agent: : Ferguson, Brandon M.

Client: Batchelor, Deshawn Evans

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