CFTSS Request for Services Form : Services : Abbott House

CFTSS Request for Services Form

Today's Date

Month

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 *

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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

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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

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