Service Request Form For Extended

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Service Request Form
for Extended Psychotherapy/Counseling
Phone Number: 1-800-818-5837 Fax Number: 1-866-617-4967
Section 1
Member Information
Member Name: (Last, First, MI)
Date of Birth:
Member I.D:
/
/
Address: (No., Street, City, State, Zip)
Phone Number:
(
)
Service is:
☐ Initial Request ☐ Updated Request
Section 2
Provider Information
Provider rendering services (Include Degree):
Phone Number:
Fax Number:
(
)
(
)
Agency:
Address: (No., Street, City, State, Zip)
Provider/Supervising Signature (Include Degree):
Court ordered service: ☐ Yes ☐ No (court order signed must be attached) DFPS Directed Service: ☐ Yes ☐ No (DFPS doc attached)
Section 3
Care Coordination Contacts
Is treatment being coordinated with a PCP? ☐ Yes ☐ No
Is treatment being coordinated with a psychiatrist? ☐ Yes ☐ No
If yes; Name:
If yes; Name:
Section 4
DSM-IV Diagnostic Codes
Axis I (Include All):
Axis II:
Axis III:
Axis IV:
GAF: Current:
Highest In Past 12 months:
Section 5
Medication
Is Member on current psychiatric and/or medical medications? If yes, please complete below. Use separate sheet if more space is needed.
MEDICATION
DOSAGE
RESPONSE
MEDICATION
DOSAGE
RESPONSE
Section 6
Symptom List (Check All That Apply)
a.
Psychosis:
☐ Hallucinations
☐ Delusions
☐ Loose Associations
☐ Dissociation
☐ Inappropriate Affect
b.
Mood:
☐ Depressed Mood
☐ Hypomania
☐ Mania
☐ Sleep Disturbance
☐ Concentration
☐ Weight Loss/Gain
☐ Loss of Motivation/Pleasure
☐ Worthlessness / Guilt
c.
Anxiety:
☐ Panic Attacks
☐ Chronic Worrying
☐ Obsessive Thoughts
☐ Compulsive Behaviors
☐ Hyper Vigilance
☐ Phobia
d.
Cognitive:
☐ Dementia
☐ Delirium
☐ Distractible
e.
Somatic:
☐ G. I.
☐ Pain
☐ Conversion/Pseudonuerologic
f.
Development Disorders:
☐ Autism
☐ Aspergers
☐ Mental Retardation ☐ Other Learning Problems
g.
Disruptive Behavior:
☐ Oppositional/Conduct
☐ Impulsivity
☐ Hyperactivity
☐ Aggressive
☐ Attention
h.
Substance:
☐ Abuse
☐ Dependence (Specify Type) _____________________________________________________________________
i.
Learning/School/Work Problems: ___________________________________________________________________________________________________
j.
Other Symptoms (Specify) _________________________________________________________________________________________________________
k.
Suicidal Ideation: ☐ Yes
☐ No
Homicidal Ideation: ☐ Yes
No
Other Self Harm:
☐ Yes
☐ No
Section 7
Treatment Type / Modality / Goals (Check All That Apply)
Type:
☐ Individual
☐ Family
☐ Group
Modality:
☐ Cognitive Behavioral
☐ Interpersonal (Including Family Systems Therapy)
☐ Other (Specify):
☐ Chemical Dependency
☐ Support / Educational
Goals:
☐ Behavior/Cognitive Change
☐ Mood/Affect Change
☐ Insight Into Problems
☐ Environmental/Relationship Change
☐ Supportive Treatment (Maintain Current Functioning)
☐ Other (Specify):
Progress:
☐ Improved
☐ Unchanged
☐ Regressed
Section 8
Service Request
Date of initial visit:
# of visits:
Freq:
Duration:
CPT Code(s):
Section 9 Behavioral Health Authorization
Authorization #:
Approved # of Visits:
Approved Freq:
Approved Duration:
This is not a guarantee of benefits, only a review of the requested services for appropriateness and necessity. Reimbursement is based on the benefits available
at the time of the service.
Signature : _____________________________________________________________ Title: ______________________________________________________
*Please attach additional information, if necessary.
For DALLAS Service Area STAR+PLUS Behavioral Health Services, contact NorthSTAR at
888-800-6799 or
6905TX0710

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