Interim Child Eligibility Determination Form printable pdf download

Interim Child Eligibility Determination Form

New Hampshire Bureau of Behavioral Health

Interim Child Eligibility Determination Form

June 30,2012 – June 30, 2013 or CANS implementation date, whichever occurs first

CMHC ________________________________________

Criterion I: Diagnosis: He-M 401.02 (u) “Serious emotional disturbance” means severe mental disability in

persons under the age of 18, and includes psychiatric disorders classified as axis I disorders or an axis II

borderline personality disorder in the DSM-IV-TR with the exception of substance abuse disorders and V codes,

which are conditions not attributable to a mental disorder. Please list the diagnoses and codes below:

DSM-IV-TR Diagnosis and Code: _______________________________________

Criterion II: Functional Impairment Due to Serious Emotional Disturbance: The definition below shall

be used during the period June 30, 2012 – June 30, 2013 or the CANS implementation date, whichever occurs

first. Functional Impairment Due to Serious Emotional Disturbance shall mean moderate needs (a score of 2) in

at least three areas or severe needs (a score of 3) in at least one area or at least moderate needs (a score of 2) in

Home Environment. Please indicate level of need and provide narrative describing current (within past six

months) impairment in these areas:

0 – No evidence of any current needs, or any

2 – Experiencing functional impairments requiring

history of impairment in this area.

interventions.

1 – Requires ongoing monitoring but not a need for

3 – Requires immediate interventions due to the

current interventions; the child may also have a past

severity of symptoms or impairments.

history of impairments (not current) in this area.

SCHOOL FUNCTIONING

HOME FUNCTIONING

COMMUNITY FUNCTIONING

INTERPERSONAL DIFFICULTIES

Interim Child Eligibility Determination Form