Donate
Give to Abbott House
Who You Help
Children and Families
Individuals With Developmental Disabilities
Foster Families
Your Community
Devon's Story
How You Help
Donate
Donating Goods & Services
Volunteer
Become a Foster Parent
Abbott House Golf Outing
Why Abbott House
Mission
History
Services - Children and Families
Services - Individuals with Developmental Disabilities
Leadership
Best Foster Parents Ever
Careers
Important Documents
Contact Us
CARF Accredited
Services
For Children and Families
For Adults with Developmental Disabilities
Become a Foster Parent
Health Home Services
Child and Family Treatment and Support Services (CFTSS)
Home and Community Based Services (HCBS)
News and Announcements
News
60th Anniversary Celebration Gala
Menu
Donate
Give to Abbott House
Who You Help
Children and Families
Individuals With Developmental Disabilities
Foster Families
Your Community
Devon's Story
How You Help
Donate
Donating Goods & Services
Volunteer
Become a Foster Parent
Abbott House Golf Outing
Why Abbott House
Mission
History
Services - Children and Families
Services - Individuals with Developmental Disabilities
Leadership
Best Foster Parents Ever
Careers
Important Documents
Contact Us
CARF Accredited
Services
For Children and Families
For Adults with Developmental Disabilities
Become a Foster Parent
Health Home Services
Child and Family Treatment and Support Services (CFTSS)
Home and Community Based Services (HCBS)
News and Announcements
News
60th Anniversary Celebration Gala
Services
CFTSS Request for Services Form
Today's Date
Month
January
February
March
April
May
June
July
August
September
October
November
December
Month
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
/
Year
Child's Name
First Name *
Middle
Last Name *
Date of Birth (Required)
Medicaid/CIN # (Required)
Person Making Referral
First Name *
Last Name *
Contact Number (Required)
Referring Agency Name
Contact Number
Care Coordinator Name:
First Name
Last Name
Contact Number
Case Planner Name
First Name
Last Name
Contact Number
Manage Care Company Name (Required)
Contact Number: (Required)
Member ID# (Required)
Basic Demographics
Child's Current Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
e4gxw84p8jk1
Gender
Male
Female
Not Known
School Name: (Required)
School Address
Country
Address Line 1 *
City *
State/Province *
Postal Code *
If other please specify below
School Contact Name/Title
First Name
Middle
Last Name
School Contact Number: (Required)
Caregiver Information:
Name
First Name *
Last Name *
Primary Contact Number: (Required)
Second Contact Number:
Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Presenting Behaviors (Please Explain) (Required)
Supporting Documentation
No file selected
Clear All Files
Click or drag here to add files
CFTSS Services Requested
*Please Note*
Child must be Medicaid-eligible
Services requested must meet Medical Necessity Criteria
Must be recommended by an Other Licensed Practitioner (OLP)
Must have MCO authorization
OLP (Other Licensed Practitioners) Medical Necessity
OLP Licensed Evaluation / Assessment
OLP Psychotherapy
OLP Crisis Interventions
CPST (Community Psychiatric Supports and Treatment)
Psychosocial Rehabilitation
Donate
Become A Foster Parent
Contact
Stay In Touch
Sign up for news about who you help.
Watch our Videos
See first-hand the impact you make.