Request for initial services
Reason for referral
Request for continued services
Member information
Member name
/ /Member ID #
/ /DOB
// /
Member address
/ /Phone
/- -
City
/ /State
/ /ZIP
/Clinical hub provider information
Type:
/Intensive care coordination (ICC)
/In-home therapy (IHT)
/Outpatient therapy
Agency name
/ /Phone
/- -
Provider name
/ /Contact name
/Therapeutic mentoring provider information
Mentor name
/ /NPI #
/Agency name
/ /Tax ID #
/Agency address
/ /Phone
/- -
City
/ /State
/ /ZIP
/Contact name
/Contact phone
/- -
/Contact fax
/- -
Diagnosis and clinical information Submission of this form does not guarantee authorization of your request. Please reference DSM diagnosis codes in the table below.
Axis I
/Axis II
/Axis III
/Axis IV
/Axis V
/ // /
/Date of the therapeutic mentoring provider’s most recent contact with the hub
/ /
/Date of the hub’s most recent Child and Adolescent Needs and Strengths (CANS) assessment
/ /
/Date of the hub’s most recent treatment or care plan for the youth
Is the youth currently receiving ICC services? Yes No
If yes, when did the therapeutic mentoring provider last attend a care planning team meeting?
// /
Treatment goals
How often and for how long do you meet with the youth?
/Goal
/Progress toward goal
Example: Increase youth’s social skills
/Example: Youth is now able to approach peers, ask them a question, and engage in conversation.
Describe the youth’s discharge plan.
/Today’s date / / / / Date range of requested sessions from / / / / to / / /
5308O 07095 Form available at tuftshealthplan.com/providers Phone: 888-257-1985