THERAPEUTIC RESIDENTIAL SERVICE REQUEST FOR CHILDREN AND ADOLESCENTS
FAX: (855) 825-3165
PLEASE TYPE ALL INFORMATION. NOTE THAT REQUEST WILL NOT BE ACCEPTED UNLESS COMPLETED IN
DETAIL WITH ALL SUPPORTING INFORMATION ATTACHED.
Name: Click here to enter text.
DOB: Click here to enter text.
CIS #:Click here to enter text.
AHCCCS #:Click here to enter text.
Current status: ☐T19/ ☐NT19
Other members of CFT: ☐DCS ☐JPO ☐DDD ☐other
Treating Doctor/NP, Name and phone number:__Click here to enter text.
PNO/Clinic: Click here to enter text.
Requesting clinician/ title:Click here to enter text.
Phone and email address of requesting clinician: Click here to enter text.
Guardian: Parent: Click here to enter text.
DCS: Click here to enter text.
Requested Level of Care: ☐ RTC ☐BHRF ☐HCTC
Is request urgent (IF marked urgent please explain the health and safety risk to expedite a clinical decision on this level
of care to a 3 business day decision. All supporting documentation will need to be included within 24 hours of an Urgent
Request.: ☐ Y ☐N If yes, explain (required): Click here to enter text.
Current location of member: (i.e. inpatient, foster care, family) Click here to enter text.
How long at this location If request is for higher level of care, please provide current services/ safety plan:
to enter text.
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Clinical summary and rational for request from CFT including specific, detailed symptoms/duration/ legal history/ charges
/ stressors/ complicating issues with in the last 3 months:Click here to enter text.
Diagnosis including substance use /abuse/dependence: Please be detailed including developmental disability if applicable.
Axis I Click here to enter text.
Axis II Click here to enter text.
Axis III Click here to enter text.
Current psychiatric and therapeutic services: with frequency of each/ dates of service provided and effect?
Target Symptoms Type of service
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Exact Dates of services
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Effect
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Prior services provided with desired impact/ actual impact/ compliance (within past 90 day’s minimum and any
pertinent earlier information, i.e.: other levels of care)? Click here to enter text.
1: Risk of Harm: What are the behaviors occurring the past 30- 90 days that require placement? Please include
details/ frequency/ intensity/ dates: Click here to enter text.
THERAPEUTIC RESIDENTIAL SERVICE REQUEST FOR CHILDREN AND ADOLESCENTS
FAX: (855) 825-3165
2: Functioning:
Please describe in detail serious impairment of functioning that is directly caused by psychiatric symptoms and persists in
the absence of stressors and impairs recovery. Please specifically identify: Click here to enter text.
3: Expected improvement: give clear and specific goals for placement and how this patient will be able to meet these
goals given any issues that are a baseline for this patient (ie: cognitive disabilities etc.) What will be expected functioning
ability at the time of discharge from residential treatment? Click here to enter text.
Treatment need/ current functioning
Goal level of functioning for discharge
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4. Discharge plan: Aftercare plan to include recommendations from all members of team including treating MBHP
(Please state specific goals/ likely target symptoms). Provide a detailed plan for d/c goals for the member from
residential treatment, plan A and Plan B.
Plan A
Target symptoms
Best practice treatment
Frequency
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Where will patient reside after d/c from residential treatment and what treatment will be provided? Click here to enter
text.
Plan B
Target symptoms
Best practice treatment
Frequency
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Where will patient reside after d/c from residential treatment and what treatment will be provided? Click here to enter
text.
Plan C
Target symptoms
Best practice treatment
Frequency
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Where will patient reside after d/c from residential treatment and what treatment will be provided? Click here to enter
text.
Requesting clinician/ Click here to enter text. SIGNATURE/ DATE______________________________________
Supervisor Name: Click here to enter text. SIGNATURE/ DATE:_____________________________________
THERAPEUTIC RESIDENTIAL SERVICE REQUEST FOR CHILDREN AND ADOLESCENTS
FAX: (855) 825-3165
Current Psychiatric Medication list with dosages and effect:
Name of medication
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Dose
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Target Symptoms
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Effect/ duration of trial/ compliance
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THE FOLLOWING MUST BE COMPLETED BY PSYCHIATRIC PROVIDER OR MEDICAL DIRECTOR IF NOT
ASSIGNED OR ASSIGNED PROVIDER IS NOT AVAILABLE.
Detailed Clinical summary from treating psychiatric provider for past year:
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Clinical opinion and rationale (based on level of care criteria) of psychiatric provider for placement request:
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Printed Name of Provider: Click here to enter text.
Signature of provider / Date:____________________________________________
The following must be completed by PNO Medical Director: Review of criteria and clinical rational for
recommendation: Click here to enter text.
Printed Name of Medical Director or Designee:Click here to enter text.
Signature of provider / Date:____________________________________________