Eb Behavioral Form (Minor)

Please fill in the details below carefully. All information will be kept confidential.

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Name *

First

Last

Date of birth *

Gender *--- Select Choice ---MaleFemaleOthers

Client Address Line 1 *

Client Address Line 2 *

City *

State *--- Please Select ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingChoice 57

Zip code *

Client E-mail *

Phone Number *

Client Social Seciurity Number *

Client Medicaid# *

Parent/Guardian Contact: *

First

Last

Relationship *

Parent/Guardian Contact Number *

Parent/Guardian E-mail *

Is the client on medication? *

• Yes
• No

ICD-10 Primary Diagnosis *--- Select Choice ------Please Select---F20 - SchizophreniaF21 - Schizotypal DisorderF22 - Delusional DisordersF23 - Acute and Transient Psychotic DisordersF25 - Schizoaffective DisordersF31 - Bipolar Affective DisorderF32 - Major Depressive Disorder, Single EpisodeF33 - Major Depressive Disorder, RecurrentF34 - Persistent Mood (Affective) DisordersF40 - Phobic Anxiety DisordersF41 - Other Anxiety Disorders (Generalized Anxiety Disorder)F42 - Obsessive-Compulsive Disorder (OCD)F43 - Reaction to Severe Stress and Adjustment Disorders (PTSD)F44 - Dissociative (Conversion) DisordersF45 - Somatoform DisordersF48 - Other Neurotic DisordersF50 - Eating Disorders (Anorexia Nervosa, Bulimia Nervosa)F51 - Nonorganic Sleep DisordersF52 - Sexual Dysfunction not caused by organic disorderF60 - Specific Personality Disorders (Borderline, Antisocial, etc.)F63 - Habit and Impulse DisordersF68 - Other Disorders of Adult Personality and BehaviorF70 - Mild Intellectual DisabilitiesF71 - Moderate Intellectual DisabilitiesF72 - Severe Intellectual DisabilitiesF73 - Profound Intellectual DisabilitiesF79 - Unspecified Intellectual DisabilityF80 - Specific Developmental Disorders of Speech and LanguageF81 - Specific Developmental Disorders of Scholastic SkillsF82 - Specific Developmental Disorder of Motor FunctionF84 - Pervasive Developmental Disorders (Autism Spectrum Disorder)F90 - Attention Deficit Disorder (ADHD)F91 - Conduct DisordersF93 - Emotional Disorders with Onset Specific to ChildhoodF94 - Disorders of Social Functioning with Onset Specific to ChildhoodF95 - Tic Disorders (including Tourette’s Syndrome)F99 - Unspecified Mental Disorder

Is youth currently in mental health outpatient or inpatient treatment? * *

• Yes
• No

Current Frequency of Treatment *

• Yes
• No

The youth has been engaged in active, documented outpatient treatment for:---Please Select---Less than one monthBetween one and three monthsSix months or more

Current frequency of treatment provided to this individual: *--- Select Choice ---At least 1x/ weekAt least 1x/ 2 weekAt least 1x/ monthAt least 1x/ 3 monthsAt least 1x/ 6 months

In the past three months, how many ER visits has the youth had for psychiatric care? *--- Select Choice ---No visits in the last three monthsOne visit in the last three monthsTwo or more visits in the last three months

Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting *

• Yes
• No

Does the youth have a Targeted Case Management referral or authorization? *

• Yes
• No

In the past three months, how many ER visits has the youth had for psychiatric care? *

• No visits in the last three months
• One visit in the last three months
• Two or more visits in the last three months

Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting *

• Yes
• No

Does the youth have a Targeted Case Management referral or authorization? *

• Yes
• No

Has medication been considered for this youth? *

• Not Considered
• Considered and Ruled Out
• Initiated and withdrawn
• Ongoing

Is their a current threat to the youth's ability to be maintained in their customary setting? *

• Yes
• No

Is their any emerging risk to the safety of the youth or others? *

• Yes
• No

Is their any significant psychological or social impairments causing serious problems with peer relationships and/or family members?

• Yes
• No

What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth's symptoms and functional behavioral impairments resulting from mental illness? *

How will PRP serve to help this youth get to age appropriate development, more independent functioning and independent living skills? *

Has a crisis plan been completed with family and/or guardian? *

• Yes
• No

Has an individual treatment plan/Individual rehabilitation plan been completed? *

• Yes
• No

Provider Agency/Organization Name

Provider Name and Credentials *

Phone Number

Email *

Clinical Supervisor (If applicable)

Signature

DATE

Submit