Forms

Behavioral/Physical Health Form

• Behavioral/Physical Health Coordination Form (PDF)

Inpatient and Residential Treatment for Substance Use Disorder (SUD)

• Initial Assessment Form for Substance Use Disorder Treatment Admission (PDF)
• Reassessment Form for Continued Substance Use Disorder Treatment (PDF)
• Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form (PDF)

Outpatient Treatment Request (OTR) Form

• Applied Behavioral Analysis Treatment OTR (PDF)
• Applied Behavioral Analysis Treatment OTR Checklist (PDF)
• Intensive Outpatient/Day Treatment Form Mental Health/Chemical Dependency (PDF)
• Outpatient Treatment Request (OTR) Form (PDF)
• Psychological or Neuropsych Testing Authorization Request Form (PDF)

Discharge Consultation Documentation

• Discharge Consultation Documentation (PDF)