CRF-DD by niusheng11


									                                          Southeastern Center for MH/DD/SAS
                              Developmental Disabilities Certification Request Form (DD-CRF)
Requested Start Date for Certification:                                         Needs, Behaviors, Risks: Please check all applicable boxes:
           End Date for Certification:                                             Assistance/Training in Daily Living Skills
Type of Review Requested: (select only one)                                        Physical Aggression        Verbal Aggression
                                                                                   Intensive training needed to maintain client in current residence
 Prospective       Concurrent           Retrospective
                                                                                   At risk for out of home placement
                                                                                   At risk of exclusion from services or community involvement
Date of most current PCP: Completed On:         Expiration
                                                                                   Support/Training needed in skill development
Date of most recent CCA/Psychological Evaluation:
                                                                                   At risk of hospitalization or institutionalization
                                                                                   Co-occurring          MH       SA
Consumer Information: LME Medical Record #:
Consumer Name:         DOB:
                                                                                Request for Continued Treatment (Please check all that apply)
CAP Recipient:   Yes      No
                                                                                  Remains at high risk Risk Reduced Risk minimal
Consumer Residence or Current Location:
                                                                                  Impairment significant Impairment Function improving
    Facility    Foster Home             Residential             Homeless
                                                                                  Highly symptomatic Symptoms improving Self management of
    Home/Family     Skilled Nursing     Jail/Detention          Other
                                                                                symptoms      Regressing No/ limited progress towards goals/obj.
                                                                                  Slight progress Goals Met
Service Requested:
             Other                                                              Barriers to Discharge/Lower level of care: (Please check all that apply)
 Frequency of Service:                                                            Legal Mandate Discharge treatment setting not available
 Service Schedule:                                                                Transportation    Lack of Adequate Housing/Residence
 For Concurrent Requests Only:                                                    Lack of Community/Natural Supports Treatment Non-Compliance
Changes to Service Frequency/Intensity from Previous Request:       Yes    No     Necessary to Maintain Stability Functioning Dependent on Service
Reason for changes to services requested:                                         Other:
                                                                                Progress Towards goals:
DSM-IV Diagnosis: (Name/s & Code/s)
Axis I
                                                                                Additional Information/Justification:
Axis II
Axis III
Axis IV
                                                                                Provider Agency Name:
Axis V Current GAF
                                                                                Name and Credentials of designated provider for utilization review activities:
  TBI     Date of TBI:
                                                                                Contact #:                Fax #:
                                                                                Print Name & Clinical Credentials of Person Completing this form:
Current SNAP Index Score:               Date of current SNAP:
List Natural Supports:                                                               I affirm that by signing this form, I am attesting to the information being
                                                                                provided here to be an accurate and true representation of the consumer and
Current meds?      Yes      No    If yes, please complete below:                his/her clinical needs. Service being requested aligns with the consumer’s
 Medication/Condition             Dose      Frequency Usually Adherent?         diagnosis and current level of functioning. Consumer and/or consumer’s
 Treated                                                                        guardians are in agreement with service and frequency being requested.
                                                         Yes       No           Consumer’s needs are frequently assessed and modifications to services provided
                                                         Yes       No           are made to reflect consumer’s current needs and level of functioning. Service
                                                         Yes       No           and frequency are correctly reflected in consumer’s current Person Centered Plan
                                                                                and Comprehensive Clinical Assessment.
                                                         Yes       No
Revised 11/10
                                     Instructions for Southeastern Center for MH/DD/SAS
                                Developmental Disabilities Certification Request Form (DD-CRF)
Requested Start date for Certification: Enter date                                  TBI: Check box if a TBI consumer. Enter date of TBI causing incident
Requested End date for Certification: Enter date
Type of Review Requested: Check type of review.                                     NC SNAP: Enter NC SNAP index score and date of most current SNAP.

Date of most current PCP: Enter date PCP completed and expiration date of           Natural Supports: List natural supports readily available to consumer.
current Person Centered Plan
Date of most recent CCA/Psychological Evaluation: Enter date of most recent         Current meds: Check if currently prescribed psychotropic medications. If so enter
CCA or Psychological Evaluation.                                                    the Name/Reason, Dosage, Frequency and if consumer is usually compliant with
                                                                                    taking the given medication.
Consumer Information: Enter consumer’s name, DOB, and LME medical
record #.                                                                           Needs, Behaviors and Risks: Check all that apply.
Cap Recipient: Check whether the consumer receives CAP funded services. If
they do they do not qualify for state funded services.                              Request for Continued Treatment: Check reasons for continuation of treatment.
                                                                                    Barriers to Discharge/Lower Level of Care: Check, or write in, all items which the
Consumer Residence or Current Location: Check current location of                   Consumer is currently experiencing that may impede Consumer discharge.
consumer (ie. Facility/Hospital, Jail, etc.) or place where consumer is currently
residing.                                                                           Progress Towards Goals: Provide information regarding consumer’s progress
                                                                                    towards goals on PCP.
Service Requested: Check service.
Frequency of Service: enter the frequency amount of service being requested         Additional Information/Justification: provide any additional information that might
(hours per week, hours per month, etc.)                                             be relevant to service request including client status and progress, extenuating
Service Schedule: enter the consumer’s schedule of receiving services so units      circumstances, significant life changes, crisis, improvement in client functioning, etc.
being requested can be justified.
 For Concurrent Requests Only:                                                      Provider Agency Name: Enter Name, credentials, phone and fax numbers of
Changes to Service Frequency/Intensity from Previous Request: enter any             designated provider contact. *This person will be contacted if there are questions
changes in service frequency or intensity from previous requests.                   regarding certification request.
Reason for changes to services requested: enter reason for changes to services      Print Name & Clinical Credentials of Person Completing this form:
being requested.                                                                    Enter printed name with clinical credentials of clinician completing form.
                                                                                    Person completing this form must be a clinical professional who has adequate
DSM-IV Diagnosis: Enter Diagnostic Name & Code and complete Axis 1-V.               knowledge of consumer’s needs, services and progress, either through direct contact or
Axis I Clinical Disorders                                                           supervision.
Axis II Personality Disorders and Mental Retardation
Axis III General Medical Conditions                                                 Check Attestation Statement to affirm information provided is accurate and clinically
Axis IV Psychosocial and Environmental Problems                                     necessary. Requests without this checked will not be certified as unable to process.
Axis V Global Assessment of Functioning (GAF) Score

Revised 11/10

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