Treatment Extension/change Request Form Page 2
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TREATMENT EXTENSION/CHANGE REQUEST
For Requests to Change Authorization: Describe Change Requested (service type/frequency, etc) and Rationale:
______________________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Current Goals: Must be observable/measurable behaviors and focus specifically on the area of impairment (work, school,
health/safety, social) that enables this consumer to meet Medical Necessity Part B. Must include a baseline and frequency.
Behavioral Outcome/Goal: _______________________________________________________________________
____________________________________________________________________________________________
Behavioral Outcome/Goal: _______________________________________________________________________
____________________________________________________________________________________________
Target Date: _____________________
Current Dysfunction rating:
None
Mild
Moderate
Severe
Describe how symptoms impair functioning: __________________________________________________________
_____________________________________________________________________________________________
Method For Achieving Goal(s) and Consumer’s Responsibilities:
______________________________________________________________________________________________
______________________________________________________________________________________________
PROPOSED TREATMENT: **For providers requesting authorization through CAT only.
Refer for Psychiatric Treatment:
Yes
No If yes, need to complete a “Provider Referral Request Form”
Individual Therapy:
____session(s) per
week/
month/
quarter for ____
weeks/
months (
15/
30/
60/
90 min)
Group Psychotherapy:
____session(s) per
week/
month for ____
weeks/
months
Family Therapy:
____session(s) per
week/
month/
quarter for ____
weeks/
months (
30/
60 min)
Family Collateral:
____session(s) per
week/
month/
quarter for ____
weeks/
months (
30/
60 min)
With: ____________________________________________________________________________________
Purpose: _____________________________________________________________________________________________
Non-Family Collateral: ____ session(s) per
week/
month/
quarter for ____
weeks/
months (
30/
60 minutes)
With: ____________________________________________________________________________________
Purpose: _________________________________________________________________________________
Outpatient Consultation with: ______________________________________________________(
25/
60 minutes)
Purpose: _________________________________________________________________________________
____________________________________________
____________
Contractor’s Signature and Discipline
Date
____________________________________________
Contractor’s Printed Name and Discipline
________________________________________________________
________________
Consumer’s Signature
Date
__________________________________________________________
________________
Parent/Guardian’s Signature
Date
Mail form to: Community Access, Referral, Evaluation, & Support (CARES)* PO Box 7549*Riverside CA 92513 or Fax 951 358-5352
Confidential Patient Information. Se California Welfare & Institutions Code Section 5328
February 2012
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