Forms

BHRS are treatment and therapeutic interventions prescribed by a psychologist or psychiatrist provided on an individual basis in the person's own environment such as the home, school and community. These services include Therapeutic Support Staff (TSS), Behavioral Specialist Consultants (BSC), Mobile Therapy (MT) and specialized services, as approved.

When submitting a packet, 6 items are required: the Best Practices Evaluation, the Individual Treatment Plan, and the 4 forms that are labeled *required for packet submission below.

TSS Schedule Forms (*required for packet submission)

Life Domain BP Format for Evaluations

Guidelines for Addendums to Evaluations

ISPT Meeting Invitation

Prescriber Responsibilities at ISPT

BHRS Plan of Care Form and Directions

MST and FFT Plan of Care Form and Directions

ISPT Sign In, Confidentiality Statement, Summary and Prescriber Collaboration

Family Choice Notification

Discharge Checklist and Summary

FBA Certification Update

Enhanced School Based Partial Plan of Care Form and Directions

SUD Case Management Referral

SUD Precertification Template

SUD Continued Stay Review Template

SUD Discharge Template

Community-Based Adolescent SUD Treatment Service Referral Form

SUD Case Notification Form

2.5 PHP Services (Substance Use Partial)

Mental Health Partial Program Notification: Adult

Non-Acute Child/Adolescent Partial ISPT Meeting Attendance Request

Mental Health Partial Program Notification: Child/Adolescent

FBMHS are evaluation and treatment services provided to a specific child in a family, but focuses on strengthening the whole family system to increase their ability to successfully manage their child's behavioral and emotional issues. Services are provided by licensed agencies employing a mental health professional and a mental health worker as a team to provide treatment and case management interventions. Services are provided in the home of the family.

Precertification

Best Practice Prescription Letter

RTF services are comprehensive mental health treatment services for children with severe disturbances or mental illness. These services are provided in Residential Treatment Facilities (RTF's) which must be licensed by OCY&F under Chapter 3800. The facility must have a service description approved by OMHSAS, be certified by OMHSAS through annual on-site review, have a utilization review plan in effect and be enrolled in the MA program.

Life Domain BP Format for Evaluations

Guidelines for Addendums to Evaluations

Plan of Care Form and Directions

ISPT Invitation Form

ISPT Sign In Sheet

ISPT Summary

Family Choice Notification

Attachment 8

Discharge Summary

RTF Family Roles & Responsibilities

CRR Host Home Family Roles and Responsibilities

Allegheny County Drug & Alcohol forms

2.5 PHP Services (Substance Use Partial) and 2.1 IOP Services (Intensive Outpatient)

Family Focused Services

Joint Planning Team Referral Form

Joint Planning Team Authorization Form

Mobile Transition Age Youth Program

ACT/CTT

Specialized Services

Dual Diagnosis Treatment Team (DDTT) Referral Form

Neuro/Psychological Testing Preauthorization Request

Mental Health Precertification Template - Adult

Mental Health Precertification Template - Child

Mental Health Continued Stay Review Template

Mental Health Discharge Template

Prescribing Practitioner Reporting

Specialized Services Continued Stay Review

Extended Evaluation Service

Child/Adolescent Music Therapy

Specialized Evaluation

Project Transition Referral

CASSP Coordinator Notification Form

All County ROIs

Coordination of Benefits Discharge Review

Significant Member Incident Report Form

All Counties Fraud, Waste and Abuse Forms