Behavioral Health Initial Clinical Review Form
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1 Behavioral Health Initial Clinical Review Form (Address all areas. An incomplete form may result in a delay of your request.) Submit completed form to: Online: Provider Portal Fax: Date Form Completed: Facility Information Name of Facility: Out of State Facility (Y/N): If Yes: Must attach denial letters from in state facilities National Provider ID: Address/Service Location: Facility/Program Contact (Name): Phone: Fax: Level of Care Requested (include Billing Code): Date of Admission: Requested Dates of Service: Requested Number of Service Units: Is member currently in detention (Yes/No)? (If Yes: 1 day business TAT required for RTC LOC requests.) If Yes, Name of location: Is member involved with CYFD Juveniles Justice Services (JJS) (Y/N)? If Yes, JJS Staff Person Name/ Phone Number:
2 Member Information Member Name (First/Last): Member ID or SSN: Member DOB: Member Age: Name of Legal Guardian: Guardian Address: Guardian Phone: Consumer s currently lives with (homeless, parents/siblings): Is the member involved with CYFD-CPS (Yes/No)? Is the member currently in custody of CYFD (Yes/No)? If Yes, CYFD SW Name/Phone: Is the member involved with Adult Protective Services? If Yes, APS SW Name/Phone: Is member involved with CYFD Juveniles Justice Services (JJS) (Y/N)? If Yes, JJS Name/ Phone: Power of Attorney (POA) Name/Phone: Treatment Guardian Name/Phone: DD Waiver Status: DSM Diagnoses Upon Discharge DSM Diagnosis (Include DSM codes): Description of Medical Needs (Including DME and chronic/co-morbid conditions):
3 Participant for Treatment/Admission Has parent/guardian agreed to participate in Treatment Planning and Therapy Sessions (Yes/No)? If No, why not? Is the member medically stable (Yes/No)? Member referred to this facility by: Precipitant for Request (Describe current behaviors that justify LOC.): Interventions in the past year that have been unsuccessful and led to the need for LOC (Treatment History): Most Recent MH/SA Provider: Is the member active in a CSA? If yes, what CSA? History of Out-of-Home Placements: Family/Guardian and/or Primary Support in the past year (including participation in lower LOC treatment, if parent/guardian has not been involved please give reason): Family History of Mental Health issues:
4 Describe Current Functioning in Other Domains (school program, attendance, participation in outpatient therapy including adherence to medications, leisure activities): Language/Spiritual/Cultural Factors (How will these affect treatment engagement? Be sure to incorporate into treatment plans.): Mental Status Exam MSE was completed by (Name): Date Completed: If not completed, why not? Appearance and behavior (posture, gestures, attire, facial expressions and speech): Attention (normal, alter, impaired): Mood (normal, euphoric, agitated, sad, etc.): Affect (appropriate, inappropriate, flat, etc.): Perception (hallucinations, delusions, etc.): Thought Content/Process (logical, de-realizations, SI/HI, etc.): Orientations (time, person, place, circumstances): Insight (good/fair/poor/absent): Activities of Daily Living (i.e. within normal limits, impaired): Sleep (e.g. disturbed, early morning awakening, etc.):
5 Risk Assessment Does the member currently have suicidal or homicidal ideation? Means: Motives: Plan/Intent: Current aggression that justifies LOC: Active psychosis (describe): Other dangerous or self-injurious behaviors: Does the member have a current/history of substance abuse? SA Frequency/Duration: SA Last use: Is there any known history of substance use by family members? Does the member have a history of domestic violence (witness or harm to/by family members)? Does the member have access to guns in the home? Is the member willing/able to contract for safety?
6 Current Medications (List all MH/SA and Medical) Name: Dose: Frequency Taken: Date Started: Prescriber: Is member adherent to medication (Yes/No)? If No, why not? Response to medication: Name: Dose: Frequency Taken: Date Started: Prescriber: Is member adherent to medication (Yes/No)? If No, why not? Response to medication:
7 Initial Treatment Plan Summary of Treatment Plan (What are the identified problem areas that will be a focus of treatment?) Other factors/pertinent information impacting treatment: Discharge Plan Current ELOS (estimated length of stay): What is the preliminary discharge plan?
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