Treatment Extension/change Request Form
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RIVERSIDE MENTAL HEALTH PLAN
Page 1 of 2
CONSUMER ACCESS, REFERRAL, EVALUATION, & SUPPORT (CARES)
TREATMENT EXTENSION/CHANGE REQUEST
Type of Plan:
Medi-Cal/RCHC
Minor Consent Medi-Cal
Date: ________________
This is a request for a(n):
EXTENSION
CHANGE
Provider: ___________________________________________________
Provider #: 33___________
Provider Phone #: __________________________
Provider FAX #: __________________________________
Consumer Name: _________________________________
Consumer Date of Birth: ____________________
Consumer SS#: _____________________________
Medi-Cal #: _________________________________________
Type of Living Situation:
Group Home (for minors)
Bio-parents
Foster
Relative Placement
FFA (private foster family home for minors)
Shelter Home (for minors)
Independent Living Arrangement
IMD
SNF
Board/Care
Name of Residential Facility (if applicable): ___________________________________________________________________
Date of Placement: __________________________
Consumer’s Current Address: ________________________________________________________________________________
Phone #: __________________________
__________________________
_________________________
Diagnosis:
Axis I:
___________
______________________________________________________________________
___________
______________________________________________________________________
Axis II:
___________
______________________________________________________________________
Axis III
___________
______________________________________________________________________
Axis IV: _______________________________________________________________________________________________
Specific Psychosocial Stressors
Axis V:
_________ / _____________
Current
Highest in Past Year
Current Medication(s) and Dosage(s):
______________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Prescribed By: ___________________________________________________________________________________
Risk Assessment:
Suicide Ideation
None
Mild
Moderate
Severe
Suicide Intent:
None
Mild
Moderate
Severe
Homicidal Ideation:
None
Mild
Moderate
Severe
Homicidal Intent:
None
Mild
Moderate
Severe
If any present, describe type and frequency of ideation, plan, and means: _______________________________________
__________________________________________________________________________________________________________
Date treatment started: ___________
Total # of sessions provider has completed with this consumer: __________
Progress on Goals: Describe the consumer’s progress in meeting the previous goals (as stated on last Auth Request):
Goal (1): _________________________________________________________________________________________________
___________________________________________________________________________________________________________
Goal (2): ________________________________________________________________________________________
_______________________________________________________________________________________________
Confidential Patient Information. Se California Welfare & Institutions Code Section 5328
February 2012
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