Intensive Community-Based Services Review Form
Please fax with page 1
MEMBER INFORMATION (verify eligibility before rendering services)
Member Name ______MaineCare ID# ______D.O.B. ______
STATUS OF THREE MOST SIGNIFICANT TARGETED GOALS SINCE
TREATMENT INITIATION USING THE FOLLOWING SCALE:
N = New Goal 1 = Much worse 2 = Somewhat worse 3 = No change
4 = Slight improvement 5 = Major improvement R = Resolved
Goal Progress
Rating #
1.
2.
3.
Family/Social Involvement (Check all that apply)
c Family c Spouse/Partner c Friends c Religious group
c Community Resources c AA/NA or self-help group
Rate Overall Level of Family Involvement in Treatment Goals:
c 0 [none] c 1 c 2 c 3 c 4 c 5 [significant]
Expected Hours per Week of Parent/Guardian Involvement (65M):___
Rate Overall Level of Natural Supports Involvement with the Client/Family:
c 0 [none] c 1 c 2 c 3 c 4 c 5 [significant]
Agency Involvement check all that apply:
c DHHS c Elder Services c Corrections (Court, JCCO, etc.) c EAP
c DHHS Child Welfare c Special Ed/504 c Other
SERVICES/SUPPORT HISTORY
most recent involvement mo/yr most recent involvement mo/yr
c Natural Supports c 65M&N
c Respite c HomeBased Services
c AA/NA c Psychiatric Hospital
c Peer Support c Substance Abuse Tx
c Outpatient c Crisis Services
c Groups c Crisis Unit
c Psychiatric/Med. Mgt. c Fost/Child Welfare
c Case Management/C.I. c Adult Protective
c Section 24 c Supported Nursing Facility
c Day Treatment c Medical Hospitalization
c ACT/I.C.I. c Residential Treatment
c Other c Corrections
c None c No change from
previous review
DISCHARGE CRITERIA check all that apply:
Member may be appropriate to discharge from services when they have exhibited (choose from below) for an appropriate period of time:
c Improved functioning that can be supported by community/natural supports
c Ability to maintain progress toward goals with lower LOC
c Increased ability to independently manage symptoms as evidenced by:
c Improved ability to access and follow-through with treatment w/o this service as evidenced by:
c Other (describe):
c No change from previous review in this tx episode
DISCHARGE PLAN (check all that apply) Planned Discharge Date: ____
Service and/or supports that will need to be in place upon discharge:
First Appt. Post Discharge day/mo First Appt. Post Discharge day/mo
c Natural Supports c 65M&N
c Respite c Adult HomeBased Services
c AA/NA c DLSS
c Peer Support c Substance Abuse Tx
c Outpatient c Crisis Services
c Groups c Crisis Unit
c Psychiatric/Med. Mgt. c Fost/Child Welfare
c Case Management/C.I. c Adult Protective
c Section 24 c Supported Nursing Facility
c Day Treatment c Medical Hospitalization
c ACT/I.C.I. c Residential Treatment
c Other c Corrections
c None
65MN ONLY: CAFAS/PECFAS RATER ID#:______
Total Score: ______Subscale Scores: ______
School/Work/Preschool: ______Moods/Emotions: ______
Home: ______Self-Harmful Behavior: ______
Community: ______Substance Abuse (CAFAS Only): ____
Behavior Towards Others: _____ Thinking/Communication: _____
DISCHARGE REASONS (Use for discharge review only)
Choose only one: Actual Discharge Date: _____
c Goals Met – natural community supports without other services
c Client/Family no longer wants services
c Goals Met – lower level of service and natural community supports
c Client has turned 21 years old
c Goals Unmet – referred to a higher level of service
c Client is currently out of the home (no short-term return anticipated)
c Client/Family has stopped/refused contact
c Client/Family has moved to a different catchment area
c Client is deceased
REQUEST FOR AUTHORIZATION
Dates of Service Requested from ______to ______
65MN Units Requested Clinician ______BHP ______
Comments/Additional Info to Support Rationale for Level of Care:
______
______
______
FOR INTERNAL USE ONLY:
Date Reviewed: ______Clinician: ______
c Approved c Approved Modified
c Not Authorized/Clinical c Not Authorized/Admin
Dates: from ______to ______
Number of units approved: Clinician ______BHP ______