Family Based Mental Health Services: Pre-Cert Form

Child's name

First

Last

MA ID #

Medical Assistance ID Number

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

months? currently the

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 39 files.

Please email [email protected] if you have trouble uploading documents to this form.

Current Medications: Name, dose, and frequency

Medical Concerns:

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

Yes
No
Unknown

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.

Please email [email protected] if you have trouble uploading documents to this form.