Family Based Mental Health Services: Pre-Cert Form

Child's name *

First

Last

MA ID #

Medical Assistance ID

Date of Birth *

Gender *

Date of Best Practice Recommendation for Family Based Mental Health Services? *

Outpatient MH treatment or other community based services are inappropriate or insufficient to meet the needs of the CHILD because: *

Reason for Referral: *

Please select all that apply.

Substance Abuse: How is/will this be addressed?

SED: Describe in detail below

Risk to Self? *

None
Mild
Moderate
Severe

Risk to Others? *

None
Mild
Moderate
Severe

Is the child at risk for out-of-home placement? *

Yes
No
Unsure

Yes, the child is at risk for out-of-home placement. Please specify.

Child is at risk of placement and "other" was indicated. Please specify what type of placement if not listed.

Is child returning home from an out-of-home placement and FBMHS is needed as a step-down?

Yes
No

The child is returning home from an out-of-home placement and FBMHS is needed as a step-down. Please describe.

Family Information:

CHILD AND FAMILY STRENGTHS (Include individual strengths, family strengths, natural supports and community linkages): *

Biological Parent(s) is/are the Legal Guardian(s) *

Name of Biological Mother

First

Last

Biological Mother Address

Address Line 1

Address Line 2

City

State

Zip Code

Biological Mother Phone Number

Name of Biological Father

First

Last

Biological Father Address

Address Line 1

Address Line 2

City

State

Zip Code

Biological Father Phone Number

Legal Guardian 1 Name

First

Last

Legal Guardian 2 Name (If applicable)

First

Last

Legal Guardian(s) Address

Address Line 1

Address Line 2

City

State

Zip Code

Legal Guardian(s) Phone Number

Legal Guardian 1 Relationship

Legal Guardian 2 Relationship (If Applicable)

Are there other Mental Health Services currently being provided in this household? *

Please describe the other Mental Health services being provided.

Name of family member that has agreed to engage and work with the FBMHS team *

First

Last

Others Living in Household (If applicable)

Number of additional household members outside of guardians:

Selected Value: 0

Name

First

Last

Relationship to the child:

Name

First

Last

Relationship to the child:

Name

First

Last

Relationship to the child:

Name

First

Last

Relationship to the child:

Name

First

Last

Relationship to the child:

Describe detailed information regarding psychiatric symptoms: *

Behavior problems / significant psychosocial stressors that may interfere with child / family function in the home.

Previous and Current Treatment

Type of Treatment/Service: *

Type of Treatment/Service Dates and Providers

I will provide a current list of medications by: *

Upload a List Current Medications: Name, dose, and frequency

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Current Medications: Name, dose, and frequency

Medical Concerns:

Has the child had a physical examination in the past 12 months? *

Yes
No
Unknown

Biological detail type

Date of Exam:

Has the child had psychiatric/psychological evaluation in the past 6 months? *

Yes
No
Unknown

Date of Evaluation:

Best Practice Prescription Letter/Psychiatric or Psychological Eval Upload. *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.