InitialCertificationforCPSTand/orPSR

MemberLastName:________________________MemberFirstname: DOB:_________Age:_______Sex:___________SSN#: Medicaid#:_________________DateofAssessment:________________MIS#

PROVIDER: Name of facility and phone number:

Name of person requesting authorization and credentials: Contact number:

PRESENTING PROBLEM: Reasons for seeking services/precipitating factors:

Diagnois: Axis I Axis IIAxis IIIAxis IVAxis V- (Global Assessment of Functioning) Current medication(s) and dose?

What specific goals will be addressed during treatment prior to the next authorization?

SEVERE SYMPTOMS: Most recent behaviors and duration (describe) include risk of harm:

ONCECOMPLETEDFAXTO(18886565325)
Magellan Behavioral Health, Inc.; Magellan Behavioral Health Systems, LLC; Merit Behavioral Care; and their respective affiliates and subsidiaries are affiliates of Magellan Health Services, Inc. (collectively Magellan).

Page1of4

 MemberLastName:________________________MemberFirstname:__________________________
ACTIVITIES OF DAILY LIVING: What current inabilities does the member present that is affecting their daily living skills?

FUNCTIONAL IMPAIRMENT: School:

Home:

Community:

MEMBER STRENGTHS: What are the members strengths as identified by the client?

What are the members strengths as identified by the clinical team?

What are the strengths of the family?

MEMBER GOALS: What are the members goals for him/herself?

What are the goals of the family?

OTHER SUPPORTS: (Family, support groups, natural supports)

ONCECOMPLETEDFAXTO(18886565325)
Magellan Behavioral Health, Inc.; Magellan Behavioral Health Systems, LLC; Merit Behavioral Care; and their respective affiliates and subsidiaries are affiliates of Magellan Health Services, Inc. (collectively Magellan).

Page2of4

 MemberLastName:________________________MemberFirstname:__________________________
OTHER MH/SA SERVICES: Describe previous outpatient MH/SA services prior to your agency.

OUTCOME OF LESS INTENSIVE TX: Was member successful in previous less intensive (outpatient) treatment?

COLLABORATION: Are you working with another agency, school, or CSOC on behalf of the member?

ENGAGEMENT: Is the member engaged with those services presently?

DISCHARGE/TRANSITION PLAN: What is the projected discharge date? What is the referral plan upon discharge?

ONCECOMPLETEDFAXTO(18886565325)
Magellan Behavioral Health, Inc.; Magellan Behavioral Health Systems, LLC; Merit Behavioral Care; and their respective affiliates and subsidiaries are affiliates of Magellan Health Services, Inc. (collectively Magellan).

Page3of4

 MemberLastName:________________________MemberFirstname:__________________________
PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING THIS MEMBER:

IVDrugUser? YES NO

Pregnant? YES NO Race? White Black/AA Asian Alaskan AmericanIndian DoesMbrhavePCP? YES NO Gender? Male Female

HI/PacificIslander OtherEthnicity Other/SingleRace Unknown

ReferringAgency? OJJ DOE OBH N/A DCFS Childinvolvedwithagency? OJJ DOE DCFS N/A

Ethnicity? Cent/SoAmerican Mex/MexAmerican Cuban NonHisporNonLatino Hispanic/Latino PuertoRican Hisp/Latinunkorigin Unknown Womanwithchild? YES N/A NO PresentingProblem? Alcohol/Drug Medical/Physical Family/Children Mood/Depression OthersEmot/Health DangertoSelf/Others Trauma/Disaster SevrImprmnt/GravelyDisabled MaritalStatus? Married Divorced NeverMarried Unknown Typeofresidence? Apartment Homeless Board&Care Shelter ResidentialHotel NoResidence SingleFamilyDwelling FosterHome GroupHome/Halfway Unknown PrvtResdW/Fmly/ExtFmly/NR Substanceusewhilepregnant? YES NO N/A AdmissionDriver? ER Psychiatrist Police Therapist Probation PCP GroupHome ACTTeam School FosterCareProgram Children&YouthSvc Parent/guardian/fmly/frnd SpecializedTherapyFstrC Corrections ClinicalTeam Child&FamilyTeam(CST) MedicalHospital N/A

VeteranStatus? YES NO

UNKNOWN

ONCECOMPLETEDFAXTO(18886565325)
Magellan Behavioral Health, Inc.; Magellan Behavioral Health Systems, LLC; Merit Behavioral Care; and their respective affiliates and subsidiaries are affiliates of Magellan Health Services, Inc. (collectively Magellan).

Page4of4