"Mental Health and Substance Abuse Outpatient Reauthorization Form" - Delaware

Mental Health and Substance Abuse Outpatient Reauthorization Form is a legal document that was released by the Delaware Department of Services for Children, Youth and their Families - a government authority operating within Delaware.

Form Details:

  • The latest edition currently provided by the Delaware Department of Services for Children, Youth and their Families;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Services for Children, Youth and Their Families.

ADVERTISEMENT
ADVERTISEMENT

Download "Mental Health and Substance Abuse Outpatient Reauthorization Form" - Delaware

Download PDF

Fill PDF online

Rate (4.7 / 5) 7 votes
MENTAL HEALTH AND SUBSTANCE ABUSE OUTPATIENT REAUTHORIZATION
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
1825 Faulkland Road Wilmington, DE 19805 (302) 633-2571 or (302) 633-2591
Please fill out this form completely and call if you need assistance.
Fax this form to (302) 622-4475
Client Name _________________________________________ DOB:________________
Admission Date _____________
Facility/Program ___________________________________
If child is uninsured you must provide documentation regarding efforts made to obtain Medicaid
including date of application, dates of calls made to check on status, denial letter, missing
information letter, etc.
Total Number of sessions scheduled this past authorization period
__________
Number of sessions cancelled by family
__________
Number of sessions cancelled by therapist
__________
Number of No Shows by Client/Family
__________
Client’s diagnosis (DSM IV including codes):
What has the client been treated for?
What are the treatment goals?
What has been improved upon?
What still needs to be addressed?
Therapist Signature _______________________________________
Date___________________
MENTAL HEALTH AND SUBSTANCE ABUSE OUTPATIENT REAUTHORIZATION
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
1825 Faulkland Road Wilmington, DE 19805 (302) 633-2571 or (302) 633-2591
Please fill out this form completely and call if you need assistance.
Fax this form to (302) 622-4475
Client Name _________________________________________ DOB:________________
Admission Date _____________
Facility/Program ___________________________________
If child is uninsured you must provide documentation regarding efforts made to obtain Medicaid
including date of application, dates of calls made to check on status, denial letter, missing
information letter, etc.
Total Number of sessions scheduled this past authorization period
__________
Number of sessions cancelled by family
__________
Number of sessions cancelled by therapist
__________
Number of No Shows by Client/Family
__________
Client’s diagnosis (DSM IV including codes):
What has the client been treated for?
What are the treatment goals?
What has been improved upon?
What still needs to be addressed?
Therapist Signature _______________________________________
Date___________________