Interim Child Eligibility Determination Form Page 2
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2EMOTIONAL REGULATION
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THOUGHT CONTENT
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SUBSTANCE USE
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HOME ENVIRONMENT
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Serious Psychosocial Dysfunction: Y
/
N
Criterion III: Interagency Involvement: This criterion is required to determine category of eligibility.
Interagency Involvement (circle one): Y: SED Interagency
N: SED
Staff Signatures: He-M 401.04 (b) An eligibility determination shall be conducted by a: psychiatrist;
psychologist; pastoral psychotherapist; clinical social worker; MSRN; ARNP; RN-C; clinical mental health
counselor; marriage and family therapist; or a case manager or Masters level clinician with a co signature from
one of the approved staff above.
_________________________________.
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Staff Name; Title and Credentials
Date
Staff Name; Title and Credentials
Date
Co signature (if required)
BBH Version 2.0 June 22, 2012
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