Member Demographics Member Name: Member DOB: CT Medicaid # Requested Start Date: Level of Care. Inpatient Re-Registration/Concurrent Review Template

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1 Inpatient Re-Registration/Concurrent Review Template Member Demographics Member Name: Member DOB: CT Medicaid # Requested Start Date: Level of Service: Inpatient/HLOC Outpatient/Community Based Type of Service: Mental Health Substance Abuse Level of Care This is ALWAYS the last approved date in the previous authorization line. Select Type of Care Inpatient Hospital Inpatient Hospital Psychiatric Residential Treatment Facility RTF-P Residential Rehab Partial Hospital Admit Date: Has the member already been admitted to the facility: Yes No Calling Provider/Facility: Member s Current Location: ER Jail/Detention Facility Provider Office Home/Community Group Home Shelter Foster Home School Nursing Home PLEASE UPDATE AS Assisted Living Facility Supervised Housing Supportive Housing NECESSARY. Primary Requester / Referral Source: Court/Legal EAP Provider Employer Guardian Household Member Member Parent PCP Provider/Facility School Social Services Spouse Unmarried Partner Crises/Respite/Shelter/Safehome PRTF RTC/GH Foster Family DCF/Social Services CARES DMHAS LMHA If Member s LMHA involved, select LMHA: Birmingham Group Health Services Bridges A Community Support System, Inc Capital Region Mental Health Center Community Health Resources Community Mental Health Affiliates, Inc Community Mental Health Center F.S. Dubois Center (State Operated) Genesis Center, Inc Greater Bridgeport Community Mental Health Center Harbor Health Services Intercommunity Mental Health Group North Central Counseling Services River Valley Services River Valley Services-Old Saybrook Rushford Center Southeastern Mental Health Authority Southwest CT Mental Health System United Services Western CT Mental Health Network Western CT Mental Health Network-Danbury Western CT Mental Health Network-Torrington Western CT Mental Health Network-Waterbury Preparer: Phone #: PLEASE UPDATE AS NECESSARY. PLEASE UPDATE AS NECESSARY. Name of Place / Facility / Institution who referred member (be specific): PLEASE UPDATE AS NECESSARY. If Child, DCF Legal Status: PLEASE UPDATE AS NECESSARY. Committed CPS In-Home Delinquency Pending Dual Committed FWSN FWSN Pending Juvenile Justice N/A Non Committed Open Investigation Order of Temporary Custody Pending 136 Probate Protective Supervision Termination of Parental Rights Unknown Voluntary (age of majority) Voluntary Services Voluntary Services Pending

2 Current Risks Precipitant (why now?) Acute Psych/Soc Stressors Acute Risk Self / Others Catastrophic Event Medical Trial Unsuccessful Placement Match Unsuccessful Step-down Step-up Treatment Non-Compliant Withdraw / Relapse Other Precipitant (why now?) Narrative: (1000 CHARACTERS MAXIMUM) IF THIS BOX HAS NOT BEEN PREVIOUSLY COMPLETED, PLEASE PROVIDE A BRIEF CLINICAL REASON FOR ADMISSION. IF THIS SECTION HAS ALREADY BEEN COMPLETED, DO NOT EDIT THIS INFORMATION. Key: 0 = None 1 = Mild or Mildly Incapacitating 2 = Moderate or Moderately Incapacitating 3 = Severe or Severely Incapacitating N/A = Not Assessed Members Risk to Self If the presenting problem is risk to self then please complete this section. Describe current symptoms that support the rating (1, 2 or 3). Examples might be: whether member continues to endorse SI, with or without safety plan, level of intent, level of concern for safety if not inpatient, ability to develop a safety plan, and protective factors. Check all that Apply: Ideation Intent Plan Means Current Serious Attempts Prior Serious Attempts Prior Gestures Please provide details about most recent attempt or gesture (250 characters max): Members Risk to Others If the presenting problem is risk to others then please complete this section. Describe current symptoms that support the rating (1, 2 or 3). Examples might be: whether member continues to endorse HI, with or without safety plan, level of intent, level of concern for safety if not inpatient, ability to develop a safety plan, and protective factors. Date of most recent gesture: Check all that Apply: Ideation Intent Plan Means Current Serious Attempts Prior Serious Attempts Prior Gestures Please provide details about most recent attempt or gesture (250 characters max): Date of most recent gesture:

3 Current Impairments Key: 0 = None 1 = Mild or Mildly Incapacitating 2 = Moderate or Moderately Incapacitating 3 = Severe or Severely Incapacitating N/A = Not Assessed Mood Disturbances (depression or mania) Please provide a description of the mood disturbances as evidenced by symptomology. Weight Change (associated with a behavioral diagnosis) Please provide a description of the weight change as evidenced by symptomology. (Required if 2 or 3 selected) Weight: Gain Loss Past 3 Months: lbs N/A Current Weight : lbs N/A Height: ft in N/A Anxiety Please provide a description of the anxiety as evidenced by symptomology. Medical/Physical Conditions Please provide a description of the medical or physical conditions as evidenced by symptomology. Psychosis/Hallucinations/ Delusions Please provide a description of the psychosis, hallucinations or delusions as evidenced by symptomology.

4 Key: 0 = None 1 = Mild or Mildly Incapacitating 2 = Moderate or Moderately Incapacitating 3 = Severe or Severely Incapacitating N/A = Not Assessed Check all that apply: Alcohol Substance Abuse/ Illegal Drugs Dependence Prescription Drugs Please provide a description of the substance abuse/dependence by symptomology. Thinking / Cognitive Memory / Concentration Problems Please provide a description of the thinking, cognitive, memory, or concentration problems by symptomology. Job / School Performance Problems Please provide a description of the job or school performance problem by symptomology. Impulsive / Reckless / Aggressive Behavior Please provide a description of the impulsive, reckless, or aggressive behavior by symptomology. Social Functioning / Relationships / Marital / Family Problems Please provide a description of the social functioning, relationship, or family problems by symptomology. Activities of Daily Living Problems Please provide a description of the activities of daily living problems by symptomology. Legal Please provide a description of the legal problems by symptomology. Impairments Related to Loss / Trauma Please provide a description of the impairments from loss or trauma by symptomology. Check all that apply: Juvenile Justice Parole Probation Other Court Narrative (Required if 1, 2 or 3 selected):

5 *Behavioral Diagnoses (Primary is Required*) Diagnosis (List Diagnosis Code/ Description/ Diagnostic Category) (List Diagnosis Code/ Description/ Diagnostic Category) Other Behavioral Diagnoses (Only Primary is Required*) *Primary Medical Diagnoses (Primary is Required* or indicate None or Unknown ) (List Diagnosis Code/ Description/ Diagnostic Category) Other Medical Diagnoses (Not Required) *Social Elements Impacting Diagnoses (Required -Check all that apply) Functional Assessment (Optional) (List Diagnosis Code/ Description/ Diagnostic Category) None Educational Problems Financial Problems Housing Problems (Not Homelessness) Occupational Problems Problems with access to Health Care Services Problems related to interaction with Legal System/Crime Problems with Primary Support Group Problems related to Social Environment Unknown Homelessness Other Psychosocial and Environmental Problems: CDC-HRQOL CGAS FAST OMFAQ SF12 SF36 WHO DAS OTHER Assessment Score: Treatment History Psychiatric Treatment in the past 12 Months: Check All that Apply: Unknown None Outpatient (excluding current course of treatment) Outcome: Improved No Change Worse Unknown Treatment Compliance (Non-Med): Unknown Poor Fair Good Intensive Outpatient / Partial Hospital Program Outcome: Improved No Change Worse Unknown Treatment Compliance (Non-Med): Unknown Poor Fair Good Hospitalization (Including residential and group home) Outcome: Improved No Change Worse Unknown Treatment Compliance (Non-Med): Unknown Poor Fair Good Number of Psychiatric Hospitalizations in the Past 12 Months: Number of Psychiatric Hospitalizations in Lifetime: Substance Abuse Treatment in the Past 12 Months: Check All that Apply: Unknown None Outpatient (excluding current course of treatment) Outcome: Improved No Change Worse Unknown Treatment Compliance (Non-Med): Unknown Poor Fair Good Intensive Outpatient / Partial Hospital Program Outcome: Improved No Change Worse Unknown Treatment Compliance (Non-Med): Unknown Poor Fair Good Hospitalization (Including residential and group home) Outcome: Improved No Change Worse Unknown Treatment Compliance (Non-Med): Unknown Poor Fair Good Number of Substance Abuse Hospitalizations in the Past 12 Months: Number of Substance Abuse Hospitalizations in Lifetime:

6 Is member currently on Psychotropic Medication? Yes No Unknown Date of Most Recent Med Evaluation: Please update as necessary. If Yes: Medication: Psychotropic Medications Description: Atypical Anti-psychotics Antidepressants Unknown Classic Anti-psychotics Atypical Serotonin & Norepinephrine Blockers Anxiolytics Benzos Mood Stabilizers Others Stimulants / ADHD Meds Tricyclics Med Compliant / Administration: N/A Dosage: Prescriber: Behavioral Health MD Clinical Nurse Specialist Psychiatrist Other Primary Care MD Is Medication found to be Effective? 0 - Not Effective 1 - Minimally Effective 2 - Effective 3 - Very Effective 4 - N/A Not Assessed Side Effects: YES NO If Side Effects, Please Describe: Frequency: Daily 2X Daily 3X Daily 4X Daily As Needed Daily at Bedtime Every 2 Hrs Every 4 Hrs Every 6 Hrs Every 12 Hrs Every 8 Hrs Every 2 Wks Other Reasons for Missed Dosage: If you indicated the Member is currently on Psychotropic Medications then you must complete at least 1 medication on this tab. If there are additional meds, you can simply list them with the dosage information in this provided text box. Please include information about PRNs if applicable. The more information you provide about the medication plan, the easier it will be to determine the need to continued care.

7 Psychotropic Medications Is member currently on Psychotropic Medication? Yes No Unknown If Yes: Medication: Dosage: Prescriber: Behavioral Health MD Clinical Nurse Specialist Primary Care MD Psychiatrist Other Is Medication found to be Effective? 0 - Not Effective 1 - Minimally Effective 2 - Effective 3 - Very Effective 4 - N/A Not Assessed Side Effects: YES NO If Side Effects, Please Describe: Description: Atypical Anti-psychotics Antidepressants Classic Anti-psychotics Atypical Serotonin & Norepinephrine Blockers Anxiolytics Benzos Mood Stabilizers Others Stimulants / ADHD Meds Tricyclics Frequency: Daily 2X Daily 3X Daily 4X Daily As Needed Daily at Bedtime Every 2 Hrs Every 4 Hrs Every 6 Hrs Every 12 Hrs Every 8 Hrs Every 2 Wks Other Med Compliant / Administration: N/A Reasons for Missed Dosage: Is member currently on Psychotropic Medication? Yes No Unknown If Yes: Medication: Dosage: Prescriber: Behavioral Health MD Clinical Nurse Specialist Primary Care MD Psychiatrist Other Is Medication found to be Effective? 0 - Not Effective 1 - Minimally Effective 2 - Effective 3 - Very Effective 4 - N/A Not Assessed Side Effects: YES NO If Side Effects, Please Describe: Description: Atypical Anti-psychotics Antidepressants Classic Anti-psychotics Atypical Serotonin & Norepinephrine Blockers Anxiolytics Benzos Mood Stabilizers Others Stimulants / ADHD Meds Tricyclics Frequency: Daily 2X Daily 3X Daily 4X Daily As Needed Daily at Bedtime Every 2 Hrs Every 4 Hrs Every 6 Hrs Every 12 Hrs Every 8 Hrs Every 2 Wks Other Med Compliant / Administration: N/A Reasons for Missed Dosage:

8 Psychotropic Medications Is member currently on Psychotropic Medication? Yes No Unknown If Yes: Medication: Dosage: Prescriber: Behavioral Health MD Clinical Nurse Specialist Primary Care MD Psychiatrist Other Is Medication found to be Effective? 0 - Not Effective 1 - Minimally Effective 2 - Effective 3 - Very Effective 4 - N/A Not Assessed Side Effects: YES NO If Side Effects, Please Describe: Description: Atypical Anti-psychotics Antidepressants Classic Anti-psychotics Atypical Serotonin & Norepinephrine Blockers Anxiolytics Benzos Mood Stabilizers Others Stimulants / ADHD Meds Tricyclics Frequency: Daily 2X Daily 3X Daily 4X Daily As Needed Daily at Bedtime Every 2 Hrs Every 4 Hrs Every 6 Hrs Every 12 Hrs Every 8 Hrs Every 2 Wks Other Substance Abuse Med Compliant / Administration: N/A Reasons for Missed Dosage: SUBSTANCE ABUSE (MUST COMPLETE IF SUBSTANCE ABUSE OR ALCOHOL INDICATED) Check all that apply: Alcohol Amphetamines / Stimulants (diet pills, speed, Ecstasy, Ritalin, etc.) Barbiturates (sedatives, downers, etc.) Cocaine (crack, powder, etc.) Hallucinogens (LSD, mescaline, etc.) Inhalants (glue, gasoline, solvents, nitrates, etc.) Marijuana or Hashish Opioids (Heroin, Morphine, etc.) Over-the-counter Cold or Cough Medications (dextromethorpan, etc.) PCP (Phencyclidine) Pain Killers (Codeine, Demerol, etc.) Sleeping Pills Steroids Tranquilizers (Valium, Xanax, other anxiolytics, etc.) Other Prescription Drugs Other Non-prescription Drugs or substances Unknown

9 SUBSTANCE ABUSE (continued) Total Years of Use Length of Current Use Amount of Use Frequency of Use Date Last Used 0-5 years Less than 1 month Daily 6-10 years 1-6 months 4X per week years 6 mos-1 year 4-6X per week years 1 year or longer 2-3X per week 20+ years Unknown Unknown Withdrawal Symptoms: Check all that Apply: None Nausea Tremors Past DT s Vomiting Agitation Black Outs Current Seizures Cramping Hallucinations Current DT s Past Seizures Blood Pressure: / Temperature: Pulse: Respiration: Blood Alcohol: Blood Pressure: / N/A N/A N/A N/A N/A N/A Urine Drug Screen (UDS)? YES NO Unknown Outcome of UDS Positive Negative Pending Positive For: Longest Period of Sobriety: Less than 6 months 6 months to 2 yrs More than 2 yrs None Unknown Check all that Apply: Cannabis Opiates Cocaine Amphetamines Tricyclic Antidepressants Phenylpropanolamine Benzodiazpines Barbiturates Me PCP (Phencyclidine) LSD (lysergic acid diethylamide) Methadone Other CIWA: Dimension 1 Intoxication/Withdrawal Potential ASAM / Other Patient Placement Criteria Dimension 2 Biomedical Conditions Dimension 3 Emot/Beh/Cogn Conditions Low Medium High Narrative: Low Medium High Narrative: Low Medium High Narrative: Dimension 4 Readiness to Change Dimension 5 Relapse Potential Dimension 6 Recovery Environment Low Medium High Low Medium High Low Medium High Narrative: Narrative: Narrative:

10 Focal Treatment Plan Care Planning Team Includes: AO / Parole Staff DCF DDS Case Manager Family / Guardian Member Milieu Staff CMP Outpatient Provider Peer / FPS Psychiatrist / Nursing School LMHA (if managed) Other Date of Plan: Focal Treatment Need: (To be completed on the first concurrent review only. Update on subsequent concurrent reviews only if needed.) Why does the Member need this level of care? What is the focus of the treatment? Intervenable Factor / Goal: What symptomology are you looking to change? Measurable Objective: What do you want the Member to achieve to be ready for discharge? Intervention: How are you planning to use the units you are requesting? (Provide specific examples of medication changes, discharge planning efforts including referrals made and collaboration with other agencies, family therapy and focus, etc.)? Treatment Plan Progress Narrative: (Mandatory Entry This box is located to the right of 1. Intervenable Factor/Goal on the Focal Treatment Plan tab.) Narrative Entry box: To be utilized for providers to give a narrative of a member s progress and specifics regarding the case that otherwise were not included under the clinical impairments section. Also, please include how many units are being requested and provide justification. Any information that you would like to communicate to the clinical staff and otherwise was not included elsewhere in the review should be included in this box.

11 Treatment Request & Discharge Planning Treatment Request Information: Involuntary Admission Court Ordered Voluntary Admission DCF Override Fixed Length Program Frequency of Program Specify Length: Primary Reason for Continued Stay: Remains Symptomatic Not Achieve Treatment Goals Complete Family Therapy Complete Behavior Plan Finalize Discharge Plan Stabilize Meds Discharge Delay Primary Barrier to Progress and Treatment: Adequate Housing Residence Discharge Treatment setting not available Family not able to support Family not willing to support HX of Interrupted treatment Lack of Community Support Language Barrier Legal Mandate Par / Adult active SA in HM Par / Adult in Home is Acc Transportation Treatment non-compliance None Other Is service requested for HLOC because appropriate LLOC not available? YES NO If yes, what LLOC was needed and not available for member? Crisis Stabil OBS Bed IICAPS MST MDFT FFT FST Therapeutic Mentoring PHP IOP EDT Home Visit Home Health Psych Testing Meth Maintained EPSDT Outpatient RTC GH SA Rehab PRTF Other If Yes, Reason why appropriate LLOC not available? Check All that Apply: Does not exist in geographic area At capacity / no openings Does not provide specialty needed Member Declined Hours Not Available Determine Not Crises Family Decline Other: Expected Date of Discharge: Planned Discharge Level of Care: Community Support Team Outpatient Targeted Case Mgt Inpatient 23 Hour CSU Partial Hospital RTC GH Halfway House Day Services IOP / SOP Alternative Community Support Day Treatment Foster Care In-Home & Family Services Placement Services PRTF Residential Child Care Respite Specialty Children s Program Subacute Other Assertive Community Treatment Facility Based Crisis Intensive In-Home MST NCMC Only Ambulatory Detox NCMC Only Medically SPVSD/ADATC NCMC Only Non-Hospital Med Detox NCMC Only SA Med Monitored Resi NCMC Only SA Non Med Resi Over 21 Opioid Treatment Psychosocial Rehab SACOT Planned Discharge Residence: What ICM or Peer Services are needed? AWOL CCP/High Meadow Correctional Facility Foster Home Home Independent Living Juvenile Detention Nursing Home/SNF/Assistant Living RTC/Group Home State Hospital Therapeutic Foster Care Transfer to Alt. Psych or Rehab Facility Transfer to Medical Unknown Other: Per Check All that Apply: ICM Peer MCO None Describe follow up actions for next review (Required): Please check the narrative history box for any notes from the CT BHP Clinician on each concurrent being filled out.

12 Current Recommended Discharge Plan: Please state the specific planned discharge level of care. Efforts taken to effect discharge: Please provide specifics about referrals made (to what agency/facility, when, results) and what plan there is for the Member s housing. Significant barriers Identified for achieving any of the discharge goals: Projected Discharge Date: Select all who have discussed and are in agreement with discharge plan: Check all that apply: Family / Guardian DCF RTT Liaison CT BHP DCF Area Office / Parole Office Post Discharge Provider DMHAS DDS Regional Case Manager Resource Manager MCO/CMP LMHA Other: