Frequently Used Child and Adolescent Community Support Forms
STR Registration Form This form should be sent to Screening Triage & Referral (STR) at (704) 432-3453 after the Diagnostic Assessment has been conducted for a new consumer.
STR Registration-- user guide.pdf
Auth Form– This form must be completed and faxed to the Utilization Management (UM) Department at (704) 319-9114 prior to services starting and each time a reauthorization for additional units is required. (Not required for direct-bill Medicaid services).
Child and Adolescent Target Population- The appropriate Target Population Template needs to be completed after a Diagnostic Assessment has been conducted and faxed to the UM Department along with your authorization request. If a consumer is receiving state funded services in addition to Medicaid services, all updates to Target Population Templates should also be faxed to the UM Department at (704) 319-9114.
Discharge Event – To be completed each time a consumer is discharged from a service and faxed to the UM Department at (704) 319-9114.
Person Centered Plan (PCP) – This information must be faxed to the UM Department at (704) 319-9114 for all new consumers and anytime there is a change made to the person centered plan. (Starting June 1, 2006) www.dhhs.state.nc.us/mhddsas/announce/index.htm
PCP Admission Form-This form must be faxed to the UM Department at (704) 319-9114 after the completion of Diagnostic Assessment or with the PCP.
DHHS Incident and Death Report – This form is to be used to report Level II and Level III incidents, including deaths and restrictive interventions, involving any person receiving publicly funded MH/DD/SA services and faxed to Matthew Dilworth, Clinical Risk Manager at (704) 336-7718. www.dhhs.state.nc.us/mhddsas/manuals/index.htm#Forms
Certificate of Need (CON) – This form must be completed and signed by a physician team member and sent to Value Options prior to a consumer being placed in a psychiatric residential treatment facility (PRTF). www.dhhs.state.nc.us/dma/forms.html
ADHD Child and Family.doc
Criterion 5 – This form must be completed and sent to Value Options when a child/ adolescent no longer meet the acute care criteria for continued acute inpatient hospitalization, but require transitional services from the immediate setting in order to implement the discharge plan.
Care Review Forms – Must be completed for referrals to Whitaker School, Dorothea Dix Hospital, John Umstead Hospital and/or if an out of state placement is being considered. Contact Libby Cable at lcable@tlwf.org for more information about the Care Review Team and use of the forms.
Notification of Out of Home Community – This form must be sent to notify the legal guardian, others involved in care and treatment, the host LME where the child/ adolescent will be residing and the host community representatives as applicable i.e. the host DSS, host school, host court counselor etc. when a child/ adolescent is placed out of the county. www.dhhs.state.nc.us/mhddsas/manuals/index.htm#Forms
NCTOPPS - Must be completed by the "Clinical Home" provider for a consumer. Please contact Paula Cox at (704) 432-4267 in the Mecklenburg LME QI Department to access this information.
Court Report – Must be completed for consumers involved in the Juvenile Court System and presented during delinquency hearings. For more information regarding the use of the Court Report Template, please call Jennifer Kuehn the AMH Juvenile Court Liaison at (704) 432-0186 or Kuehnjc@co.mecklenburg.nc.us.
CHILD MH 07-08 Benefit Plan
DD 07-08 Benefit Plan
IPRS Cover Letter and
IPRS Benefit Plan Child MH/SA
IPRS Benefit Plan Child DD
