This form must be filled out in its entirely in order to allow for medical necessity and authorization for services. Please do not add diagnoses to the form.
Presenting Symptoms: Please include hx of Severity of Illness and History of Illness: Client has a history of depression, hospitalizations, SI and anxiety. Client lacks a social support system and has strained/conflictual relationships with her adult children and their fathers. Client has been unemployed for several years due to ongoing chronic pain and medical conditions. Client has been applying and appealing for disability for the past few years and struggles financially.
Attach a “Professional Assertion of Need for PRP Services”, copy of the current Treatment Plan, current Psychiatric Evaluation, Current Crisis Plan-if client is at risk for suicide, homicide or runaway status, If client is in Foster care or in DSS custody please provide copy of court papers showing guardianship