PRTF Admission template/requirements:
Up/Down at Different Facility (not a discharge to OP)
Scenario: Completing a pre-authorization review for the PRTF LOC.
Effective Date: 12/01/2015
*Please type
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A valid CON must be attached
Name/phone number of the requestor
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Name/phone number of the legal guardian
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Anticipated d/c plan (from PRTF) to include anticipated residential placement
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Anticipated family involvement (willingness to participate)
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History of PRTF treatment with dates (or other out of home placement i.e. TGH, NMGH, TFC, detention,
etc.)
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History of inpatient stays/days/dates
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History of outpatient providers with detailed explanation of why outpt has failed (why is less restrictive
LOC not indicated)
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Diagnosis (to include psych, SA, DD, personality, medical)
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Current medications
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Medical Hx/special needs (who is the PCP)
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CSOC involvement (do they support this level of care) with clear documentation from the WAA that they
support PRTF
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Full scale IQ
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History of OCDD involvement/status of referral (if applicable)
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Risk factors (family History of MI,SA, abuse (victimization vs. perpetration), trauma, SI/HI, psychosis)
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Legal Hx and current legal issues
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Compliance related issues
1
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Current mental status with most recent psych eval (within the last 30 days)
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Behaviorally measurable goals/expected outcomes from the PRTF stay
2
For additional days requested:
 Identify specific POC (what goals have been met, what goals are left, why continue at this LOC)
 Family involvement (family sessions held/pending/progress made)
 MSE/behavior/participation
 Med changes/compliance
 Change in Diagnosis
 School participation/attendance
 Specific d/c plan
 Anticipated LOS
 Coordination of care activity