Physician Certification Of Serious Emotional Disturbance printable pdf download

PHYSICIAN CERTIFICATION OF SERIOUS EMOTIONAL DISTURBANCE

CLIENT NAME: First: _________________ Last:__________________ SOC.SEC.NO __________________________

SEX: M F

RACE: (Circle all that apply): WH AS

BL AI/AN

NH/OPI

OTHER

ETHNIC HISPANIC______

PROVIDER:________________________ CLIENT ID NO. _______________ DATE OF BIRTH : _____/_____/_____

DEFINITION OF SERIOUS EMOTIONAL DISTURBANCE (SED)

(All boxes must be checked for a child to be certified as SED.)

Children with a serious emotional disturbance are persons:

from birth up to age eighteen (18),

who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder

of sufficient duration to meet diagnostic criteria specified within the DSM IV, OTHER THAN “V” codes, substance

use disorders or developmental disorders (including mental retardation) which are excluded unless they co-occur

with another diagnosable serious emotional disturbance.

DSM IV Diagnosis

Axis I:__________________________________________________________________________________________________

Axis II: _________________________________________________________________________________________________

Axis III: _____________________________________________________________________________________________

Axis IV: __________________________________________ Axis V: (GAF)

_______________________________________

AND this disorder resulted in functional impairment, which substantially interferes with or limits the child’s role or

functioning in family, school, or community activities. The functional impairment must result primarily from the

diagnosed mental, behavioral or emotional disorder, rather than being primarily the result of a substance

abuse/dependence disorder, developmental disorder (including mental retardation) or medical disorder.

Functional Impairment is defined as:

Difficulties that substantially (GAF of 60 or below) interfere with or limit a child or adolescent from achieving or

maintaining one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills.

Children who would have met functional impairment criteria during the referenced year without the benefit of treatment

or other support services are included in this definition. Functional impairments of episodic, recurrent, or continuous

duration are included unless they are temporary and expected responses to stressful events in the environment.

Briefly list the functional impairments below, and indicate where in the patient record specific, descriptive documentation can

be found regarding the functional impairments that result from the diagnosed mental, behavioral or emotional disorder.

___________________________________________________________________

I, the undersigned, do hereby certify that I have performed a medical review of the evaluation of this client and that he/she

meets the above DBHS criteria of Serious Emotional Disturbance.

____ Evaluation based on my direct examination of client within last 45 days (Valid up to one calendar year)

____ Evaluation not based on my direct examination of client within last 45 days (Valid up to 45 days)

____ Evaluation based on my participation in ongoing treatment planning/review process (Valid for period

covered by the current physician approved treatment plan)

_______________________________________________

______________________________

Physician Signature

Date of Medical Review

DBHS-3580 (06/05)

Physician Certification Of Serious Emotional Disturbance

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