Community Behavioral Health Tss Schedule Chart
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1Community Behavioral Health TSS SCHEDULER
Date:
Member Name:
MA#:
# of TSS hours currently authorized:
# of additional TSS hours requested, if applicable:
Total # of TSS hours/wk:
This form must be completed and submitted to Community Behavioral Health whenever requesting Therapeutic Staff Support (TSS) hours.
The TSS hours identified within this scheduler must correspond to the recommendations in the evaluation, which determines the rationale
for where, when, and why one to one support is needed based on behavioral data. Each day identified below must be individualized to
include the start time, end time as well as the setting (e.g., School, Camp, Community, Daycare, Afterschool Program, Home, etc.) in which
the TSS hours will be routinely delivered.
DAY/TIME
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
7:00am
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
6:00pm
7:00pm
8:00pm
Total TSS
hours/day
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Parent category: Life