From the practice of _______________________,
An affiliate of Cornerstone Behavioral Healthcare
CONTINUED STAY REVIEW
Client Name: ______________________________________
Review Type:
Client #
Client Number: _____________
Date:_____________
___Medication Management
Number of Units Requested: _____________
Frequency of visits: ___________________
Date of Diagnostic Assessment: _____/_____/_____
Primary Diagnosis:
Secondary Diagnosis (to include additional Axis I diagnosis as well as past Axis II &
Axis III information, where appropriate):
Psychological Stressors
Problems in Family Relations
Problems in Friendship/Social Relations
Legal Issues
School Problems
Work Problems
Custody/Placement Issues
Financial Difficulties
Problems in Living Situation
Physical Health
Problems with Access to Healthcare
Other Psychosocial & Environmental Problems
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__None/NA
__Mild
__Mild
__Mild
__Mild
__Mild
__Mild
__Mild
__Mild
__Mild
__Mild
__Mild
__Mild
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Moderate
__Severe
__Severe
__Severe
__Severe
__Severe
__Severe
__Severe
__Severe
__Severe
__Severe
__Severe
__Severe
Axis V Current (as appropriate):
Since last authorization, GAF score has:
__ Increased __Decreased __Not Changed __Unknown/NA
*Is member prescribed medication? __Yes __No Medications: ________________________________
______________________________________________ ____________________________________________________________________________
Clinical Indicators Justifying Service Request:
*Document the time period that describes the individual’s most recent occurrence for each
indicator that applies.
Aggressiveness:
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Within 1-10 years;
10+ years)
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Within 1-10 years;
10+ years)
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Within 1-10 years;
10+ years)
Fire Setting :
Assaultive :
Homicidal Attempt :
11-1-15 JM
From the practice of _______________________,
An affiliate of Cornerstone Behavioral Healthcare
CONTINUED STAY REVIEW
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Within 1-10 years;
10+ years)
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Within 1-10 years;
10+ years)
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Within 1-10 years;
10+ years)
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Within 1-10 years;
10+ years)
Within 1-10 years;
10+ years)
Within 1-10 years;
10+ years)
Within 1-10 years;
10+ years)
Within 1-10 years;
10+ years)
Within 1-10 years;
10+ years)
Client #
Homicidal Ideation:
Self Care Deficit:
Self-injurious Behavior:
Sexually Inappropriate Behavior:
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Suicide Attempt:
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Suicidal Ideation:
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Use of Weapons:
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Harm to Animals:
Current Severity ( None, Mild, Moderate, Severe)
Hx of Severity ( Within 7 days; Within 8-90 days; Within 3-12 months;
Treatment Progress:
__Significant __ Moderate __Minimum __None __Deteriorated __Other _______________________________
Please provide additional information to support request for services. Include all clinically
relevant materials concerning ongoing treatment and how goals are progressing.
11-1-15 JM