Service Request Form For Extended

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Service Request Form

for Extended Psychotherapy/Counseling

Phone Number: 1-800-818-5837 Fax Number: 1-866-617-4967

Section 1

Member Information

Member Name: (Last, First, MI)

Date of Birth:

Member I.D:

Address: (No., Street, City, State, Zip)

Phone Number:

(

)

Service is:

☐ Initial Request ☐ Updated Request

Section 2

Provider Information

Provider rendering services (Include Degree):

Phone Number:

Fax Number:

(

)

(

)

Agency:

Address: (No., Street, City, State, Zip)

Provider/Supervising Signature (Include Degree):

Court ordered service: ☐ Yes ☐ No (court order signed must be attached) DFPS Directed Service: ☐ Yes ☐ No (DFPS doc attached)

Section 3

Care Coordination Contacts

Is treatment being coordinated with a PCP? ☐ Yes ☐ No

Is treatment being coordinated with a psychiatrist? ☐ Yes ☐ No

If yes; Name:

Section 4

DSM-IV Diagnostic Codes

Axis I (Include All):

Axis II:

Axis III:

Axis IV:

GAF: Current:

Highest In Past 12 months:

Section 5

Medication

Is Member on current psychiatric and/or medical medications? If yes, please complete below. Use separate sheet if more space is needed.

MEDICATION

DOSAGE

RESPONSE

MEDICATION

DOSAGE

RESPONSE

Section 6

Symptom List (Check All That Apply)

Psychosis:

☐ Hallucinations

☐ Delusions

☐ Loose Associations

☐ Dissociation

☐ Inappropriate Affect

Mood:

☐ Depressed Mood

☐ Hypomania

☐ Mania

☐ Sleep Disturbance

☐ Concentration

☐ Weight Loss/Gain

☐ Loss of Motivation/Pleasure

☐ Worthlessness / Guilt

Anxiety:

☐ Panic Attacks

☐ Chronic Worrying

☐ Obsessive Thoughts

☐ Compulsive Behaviors

☐ Hyper Vigilance

☐ Phobia

Cognitive:

☐ Dementia

☐ Delirium

☐ Distractible

Somatic:

☐ G. I.

☐ Pain

☐ Conversion/Pseudonuerologic

Development Disorders:

☐ Autism

☐ Aspergers

☐ Mental Retardation ☐ Other Learning Problems

Disruptive Behavior:

☐ Oppositional/Conduct

☐ Impulsivity

☐ Hyperactivity

☐ Aggressive

☐ Attention

Substance:

☐ Abuse

☐ Dependence (Specify Type) _____________________________________________________________________

Learning/School/Work Problems: ___________________________________________________________________________________________________

Other Symptoms (Specify) _________________________________________________________________________________________________________

Suicidal Ideation: ☐ Yes

☐ No

Homicidal Ideation: ☐ Yes

Other Self Harm:

☐ Yes

☐ No

Section 7

Treatment Type / Modality / Goals (Check All That Apply)

Type:

☐ Individual

☐ Family

☐ Group

Modality:

☐ Cognitive Behavioral

☐ Interpersonal (Including Family Systems Therapy)

☐ Other (Specify):

☐ Chemical Dependency

☐ Support / Educational

Goals:

☐ Behavior/Cognitive Change

☐ Mood/Affect Change

☐ Insight Into Problems

☐ Environmental/Relationship Change

☐ Supportive Treatment (Maintain Current Functioning)

☐ Other (Specify):

Progress:

☐ Improved

☐ Unchanged

☐ Regressed

Section 8

Service Request

Date of initial visit:

# of visits:

Freq:

Duration:

CPT Code(s):

Section 9 Behavioral Health Authorization

Authorization #:

Approved # of Visits:

Approved Freq:

Approved Duration:

This is not a guarantee of benefits, only a review of the requested services for appropriateness and necessity. Reimbursement is based on the benefits available

at the time of the service.

Signature : _____________________________________________________________ Title: ______________________________________________________

*Please attach additional information, if necessary.

For DALLAS Service Area STAR+PLUS Behavioral Health Services, contact NorthSTAR at

888-800-6799 or

6905TX0710