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Authorization Request
Requested Services Header
Requested Start Date
02/23/2011
Level of Service
IP - INPATIENT/HLOC
Type of Service
Mental Health
Level of Care
G - Group Home
Type of Care
Group Home - 2.0
Admit Date
02/23/2011
Authorization#
022311-2-22
Client Authorization #
U0296814
Type of Request
CONCURRENT
Submission Date
02/24/2011
Member Name
SUSAN ASLAN
Member ID
987654321
DOB
12/02/1979
 
 
 
 
 
 
Provider Name
PETER TUMNUS
Provider ID
123456
Provider Alternate ID
712345
Vendor ID
A00003
NPI # for Authorization
N/A
TIN
00000001
 
 
 
Level Of Care
   
   
Level Of Care
G - Group Home
Type of Service
Mental Health
 
INPATIENT INFORMATION  
Yes
   
*Calling Provider/Facility
dvgfvg
Member's Guardian
  
*Member's Current Location
ER
*Primary Requestor/Referral Source
Court/Legal
 
If Member's LMHA involved, select LMHA
Admitting Physician
Phone #
*Preparer
dvgdvg
*Phone #
121 121 1212
Attending Physician
Phone #
Utilization Review Contact
Phone #
Fax
 
*Name of Place/Facility/Institution who referred member
(please be specific)
zxcfvxcv
 
*If Child, DCF Legal Status
Unknown
 
Do language and cultural needs impact treatment?
  No
If Yes, List Language/Cultural Issues
Narrative History
Narrative Entry
 
 
Provider Contacted
 
   
RTC/GH INFORMATION 
Yes
   
All Fields marked with an asterisk (*) are required when Type of Care is (RTC/GH) and review is concurrent
   
Gender
M
Gender Comment
Narrative History
Narrative Entry
 
 
*Link Person#
abc
* Area Office
Bridgeport
* DCF Legal Status
Unknown
* AO BHPD/Parole Officer Name
asdsd
* AO BHPD/Parole Phone#
121 212 2121
* AO BHPD/Parole Fax#
121 212 2111
* DDS CAMRIS ID #
asds
* DDS Case Manager
sdsd
* Date of RTC/GH Admission
02232011
* Child's Guardian
sdsd
* Child's Attorney
sdsd
 
* Facility Program
sdsd
* Facility Unit
sdsd
 
* Facility Clinician
sdsd
* Facility Phone
112 121 2121
* Clinician Phone
212 121 2121
All fields marked with an asterisk (*) are required.
Current Risks
*Precipitant (Why Now?)       
01 - Acute Psych/Soc Stressors
Please provide a brief explanation.
*Member`s Risk to Self
None
*Member`s Risk to Others
Mild
Check all that apply (*Required if Risk is Moderate or Severe)
Check all that apply (*Required if Risk is Moderate or Severe)
Ideation  
N
Intent  
N
Plan  
N
Means  
N
Current Serious Attempts  
N
Prior Serious Attempts  
N
Prior Gestures  
N
Ideation  
N
Intent  
N
Plan  
N
Means  
N
Current Serious Attempts  
N
Prior Serious Attempts  
N
Prior Gestures  
N
Did attempts require intensive medical treatment?
Did member account for his/ her own rescue?
Please provide details about most recent attempt or gesture.
Date 
Please provide details about most recent attempt or gesture.
Date 
 
Diagnosis

Axis I

Axis II
Diagnosis Code 1
290.11
Description
PRESENILE DEMENTIA WITH DELIRIUM
Diagnosis Code 1
301.12
Description
CHRONIC DEPRESSIVE PERSONALITY DISORDER
Diagnosis Code 2
Description
Diagnosis Code 2
Description
Diagnosis Code 3
Description
Diagnosis Code 3
Description

Axis III

Axis IV
Diagnosis Code 1
None
Diagnosis Code 2
Diagnosis Code 3
Check all that apply
Y- None N- Problems with access to health care services
N- Educational problems N- Problems related to interaction w/legal system/crime
N- Financial problems N- Problems with Primary support group
N- Housing problems N- Problems related to the social environment
N- Occupational problems N- Unknown
N- Other psychosocial and environmental problems  

Axis V
Current GAF Score    
11
Highest GAF Score in the Past Year    
 
Psychotropic Medications
Date of Most Recent
Med Evaluation
Unknown
No
Med changes this month?
 
If Yes, Describe Changes and Reason
Narrative History
Narrative Entry
Meds require serum
blood levels?
 
N
Date of most recent
blood draw
Unknown
No
Results of blood draw
Narrative History
Narrative Entry
1. Medication
Description



Dosage Frequency
      
  Is medication found to be effective?
Side effects?
If Yes to Side Effects, please describe
Narrative History
Narrative Entry
Prescriber



Med Compliant/Administration
(i.e. number of missed dosages)
Reasons for missed Dosage
Narrative History
Narrative Entry
2. Medication
Description


Dosage Frequency
      
  Is medication found to be effective?
Side effects?
If Yes to Side Effects, please describe
Narrative History
Narrative Entry
Prescriber



Med Compliant/Administration
(i.e. number of missed dosages)
Reasons for missed Dosage
Narrative History
Narrative Entry
3. Medication
Description


Dosage Frequency
      
  Is medication found to be effective?
Side effects?
If Yes to Side Effects, please describe
Narrative History
Narrative Entry
Prescriber



Med Compliant/Administration
(i.e. number of missed dosages)
Reasons for missed Dosage
Narrative History
Narrative Entry
4.Medication
Description


Dosage Frequency
      
  Is medication found to be effective?
Side effects?
If Yes to Side Effects, please describe
Narrative History
Narrative Entry
Prescriber



Med Compliant/Administration
(i.e. number of missed dosages)
Reasons for missed Dosage
Narrative History
Narrative Entry
Focal Treatment Plan
  
*Care Planning Team Includes:
Check all that apply.
  
AO/Parole Staff
Yes
DCF
No
DDS Case Manager
No
Family/Guardian
No
Member
No
Milieu Staff
No
CMP
No
Outpatient Provider
No
Peer/FPS
No
Psychiatrist/Nursing
No
School
No
LMHA (if managed by)
No
Other
No
 
*Date of Plan Date (MMDDYYYY)
02242011
 
*Focal Treatment Need   
Narrative History
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1. *Intervenable Factor/Goal
Narrative History
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Narrative Entry
*Measurable Objective
Narrative History
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Narrative Entry
*Intervention
Narrative History
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dfdf
Narrative Entry
Target Date   (MMDDYYYY)
Progress  
Narrative History
Narrative Entry
Date Revised   (MMDDYYYY)
Revision History
Progress Date Revised
 
2. Intervenable Factor/Goal
Narrative History
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Narrative Entry
Measurable Objective
Narrative History
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dfdf
Narrative Entry
Intervention
Narrative History
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dfdf
Narrative Entry
Target Date
  (MMDDYYYY)
Progress  
Narrative History
Narrative Entry
Date Revised
  (MMDDYYYY)
Revision History
Progress Date Revised
 
3. Intervenable Factor/Goal
Narrative History
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Narrative Entry
Measurable Objective
Narrative History
V1WSSO 022411, 10:08:39 ET
dfdf
Narrative Entry
Intervention
Narrative History
V1WSSO 022411, 10:08:39 ET
dfdf
Narrative Entry
Target Date
  (MMDDYYYY)
Progress  
Narrative History
Narrative Entry
Date Revised   (MMDDYYYY)
Revision History
Progress Date Revised
 
4. Intervenable Factor/Goal
Narrative History
Narrative Entry
Measurable Objective
Narrative History
Narrative Entry
Intervention
Narrative History
Narrative Entry
Target Date
  (MMDDYYYY)
Progress  
Narrative History
Narrative Entry
Date Revised
  (MMDDYYYY)
Revision History
Progress Date Revised
 
5. Intervenable Factor/Goal
Narrative History
Narrative Entry
Measurable Objective
Narrative History
Narrative Entry
Intervention
Narrative History
Narrative Entry
Target Date
  (MMDDYYYY)
Progress  
Narrative History
Narrative Entry
Date Revised
  (MMDDYYYY)
Revision History
Progress Date Revised
 
6. Intervenable Factor/Goal
Narrative History
Narrative Entry
Measurable Objective
Narrative History
Narrative Entry
Intervention
Narrative History
Narrative Entry
Target Date
  (MMDDYYYY)
Progress  
Narrative History
Narrative Entry
Date Revised
  (MMDDYYYY)
Revision History
Progress Date Revised
 
 
ADDITIONAL MTPPR INFORMATION
All Fields marked with an asterisk (*) are required when Type of Care is (RTC/GH) and review is concurrent
*Date Monthly Reporting
  Period Starts (MMDDYYYY)
02/23/2011
*Date Monthly Reporting
  Period Ends (MMDDYYYY)
04/08/2011
 
*MTPPR Required By
04/13/2011
   
 
Review Information
*CT BHP Care Manager
dgfg
*Phone #
232  323  2323 
 
 
THERAPY & HOME PASSES
*Number of Individual Treatment Sessions
for this reporting period
26
*Number of Individual Treatment Hours
for this reporting period
6.5
Focus of Individual Therapy
 
Narrative History  
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Narrative Entry  
 
 
*Number of Group Treatment Sessions
for this reporting period
0
*Number of Group Treatment Hours
for this reporting period
0.5
Focus of Group Therapy
 
Narrative History  
 
Narrative Entry  
 
*Is child's primary language English?
Yes
If No, did child receive services in primary language?
* Is family's primary language English?
Yes
If No, did family receive services in primary language?
Number of Recreational Treatment Sessions
for this reporting period
0
Number of Recreational Treatment Hours
for this reporting period
0
Focus of Recreational Therapy
 
Narrative History  
 
Narrative Entry  
 
 
Family Therapy
Number of Scheduled Family Treatment
Sessions during this reporting period
(Scheduled by Facility as per treatment plan)
0
Number of Family Treatment Hours
for this reporting period
 
Number of Attended Family Treatment Sessions
during this reporting period
0
   
Focus of Family Treatment
 
Narrative History  
 
Narrative Entry  
 
Results/Progress/Barriers
 
Narrative History  
 
Narrative Entry  
 
 
Names of participants in family treatment
 
Narrative History  
 
Narrative Entry  
 
   
Number of Family visits scheduled
during this reporting period
0
Number of family visits attended
during this reporting period
0
 
Detail of Family visits scheduled
 
Narrative History  
 
Narrative Entry  
 
Family Treatment Results/Progress/Barriers
 
Narrative History  
 
Narrative Entry  
 
 
Family Readiness
* How prepared to parent does the
 family/family resource feel?
Good
* How well has family/family resource
 developed new/improved skills?
Good
 
 
Family/Family Resource (FFR) Interactions
* Your rating of FFR interactions
 with child/youth
Good
* FFR ratings of interactions
 with child/youth
Good
 
* Child/youth rating of interactions
 with FFR
Good
 
Home Passes
Number of Home Passes during
this reporting period
0
 

 
 
Other Therapeutic Interventions/Focus
 
Narrative History  
V1WSSO 022411, 10:08:40 ET
erfer

  
Narrative Entry  
 
 
 
RELATIONAL PROGRESS
*Interactions with Peers
Good
*Interactions with Adults/Authorities
Good
 
*Willingness for Change
Good
*Personal Hygiene
Good
 
* Respects rights/property of others
Good
 
 
ACADEMIC ACHIEVEMENT
* Interactions with teachers
Good
* Interactions with class peers
Very Good
 
 
*Attendance - Days
23
*If Regular Ed student, progress in achieve grade level
Very Good
 
 
*Completes assignments
Very Good
 
*If Special Ed student, progress in achieve IEP goals
Very Good
 
 
SKILLS OF INDEPENDENT LIVING
*Self Care
Very Good
*Work Life
Fair
 
*Daily Living
Very Good
*Career Planning
Fair
 
*Housing & Home Management
Very Good
*Social Relationships
Good
 
*Home Life
Very Good
*Communication
Good
 
*Work and Study
Very Good
 
*OVERALL Assessment of progress
Very Good
 
 
*Employment/Summer jobs on campus
 
Narrative History  
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asdsd

  
Narrative Entry  
 
 
 
INCIDENTS FOR THIS REPORTING PERIOD
* Number of AWOLS
for this reporting period
 
0
              Dates of AWOLS      
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
AWOL Information
 
Narrative History  
 
Narrative Entry  
 
* Number of POLICE Interventions
for this reporting period
 
0
  Dates of Interventions
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
ARREST Information
 
Narrative History  
 
Narrative Entry  
 
* Number of ARRESTS
  for this reporting period
 
0
  Dates of ARRESTS
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
*Safety: Number of Requests for 1:1 staffing
  for this reporting period
 
0
  Dates of Requests
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
*Number of 1:1 Hours Provided
  for this reporting period
0
* Number of Restraints
for this reporting period
 
0
  Dates of Restraints
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
Describe Restraint Detail
 
Narrative History  
 
Narrative Entry  
 
* Number of Restraint related injuries
  for this reporting period
 
0
  Dates of Restraint related injuries
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
* Number of Seclusions
for this reporting period
 
0
  Dates of Seclusions
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
Describe Seclusion Detail
 
Narrative History  
 
Narrative Entry  
 
* Number of Seclusion related injuries
  for this reporting period
 
0
  Dates of Seclusion related injuries
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
* Number of Mechanical Restraints
for this reporting period

 
 
0
  Dates of Mechanical Restraints
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
Describe Mechanical Restraint Detail
 
Narrative History  
 
Narrative Entry  
 
* Number of Mechanical Restraint related injuries
  for this reporting period
 
0
  Dates of Mechanical Restraint related injuries
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
* Number of PRN Meds Administered
  for this reporting period
 
0
  Dates of PRN Meds
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
Enter PRN Med info/response
 
Narrative History  
 
Narrative Entry  
 
* Number of Suicidal/SIB assessments (Internal)
  for this reporting period
 
0
  Enter SIB assessment information
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
Enter SIB assessment information
 
Narrative History  
 
Narrative Entry  
 
* Number of ED Visits
  for this reporting period
 
0
  Dates of ED Visits
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
Enter ED Visit information
Narrative History  
 
Narrative Entry  
 
* Number of Inpatient Admissions
  for this reporting period
 
0
  Dates of Inpatient Admissions
1. 
2. 
3. 
4. 
5. 
 6. 
 7. 
 8. 
 9. 
10.
 
Enter Inpatient Admission information
 
Narrative History  
 
Narrative Entry  
 
Treatment Request & Discharge Planning
   
RTC/GH DISCHARGE PLANNING  
Yes
   
*Preliminary Discharge Plan
 at time of admission
xcvxcv
 
*Efforts taken to affect discharge
xvcdv
 
*Significant Barriers identified for
 achieving any of the discharge goals
dfdf
   
 
*Current Recommended Discharge Plan
Narrative History
V1WSSO 022411, 10:08:39 ET
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Narrative Entry
 
 
*Efforts taken to effect discharge
Narrative History
V1WSSO 022411, 10:08:40 ET
dfd
Narrative Entry
 
*Significant Barriers identified for
 achieving any of the discharge goals
Narrative History
V1WSSO 022411, 10:08:39 ET
dfd
Narrative Entry
   
*Select all who have discussed and are
 in agreement with discharge plan
Check all that apply
*Projected Discharge Date (MMDDYYYY)
02242011
 
Name relationship with whom
child will be placed
   
Family/Guardian
Yes
DCF RTT Liaison
CT BHP
DCF Area Office/Parole Office
Post Discharge Provider
DMHAS
DDS Regional Case Manager - Resource Manager
MCO/CMP
LMHA
Other
No
   
Will new congregate treatment
setting be required post discharge?
No
Date of CANS submission
 
LOC Determined
    
Peer/Family Specialist Referral made?
  No
If Yes, Date of Referral
DDS Referral Indicated?
No
If Yes, Date of Referral
 
DMHAS Referral Indicated?
No
If Yes, Date of Referral
   
Child Specific Conference
Needed/Held?
No
Date of Conference
No
N/A
Purpose of Conference
Narrative History
Narrative Entry
Case Specific Conference
Needed/Held?
No
Date of Conference
No
N/A
Purpose of Conference
Narrative History
Narrative Entry
 
*Educational placement (PRT)
 review needed?
 
No
Date of/for PRT
   
PPT Needed?
 
No
Date of/for PPT
Additional Comments
Narrative History
Narrative Entry
 
*Has Member Been Discharged?
Yes
If Yes, Actual Date
of Discharge
02242011
 
Child/Family Case Worker Needs
Describe Needs/Why By Whom/By When
Narrative History
V1WSSO 022411, 10:08:40 ET
dfdf
Narrative Entry
   
Name of RTC Therapist Individual
Completing MTPPR
 
 
Title/Position
 
 
*DCF Worker Name
dfdf  
*DDS Case Manager Name (if applicable)
sdfdfdf  
 
*CTBHP Reviewer
dfvdf
 
*CTBHP Reviewer Phone #
121  121  2121   
 
Date Completed
02242011