Forms for Treatment Services Providers and Ancillary Services Providers
These forms are for any provider rendering services to youth active with the Division of Prevention and Behavioral Health Services (DPBHS)
Standardized DPBHS Treatment Service Forms
(admission, treatment, discharge, etc)
As outlined by contractual expectation and obligation, these are the standardized forms required for providers rendering services to youth active with the Division of Prevention and Behavioral Health Services (DPBHS)
This is a mandated assessment tool for any active substance abuse treatment provider for DPBHS to be used in accordance to the guidelines specified by the DPBHS Treatment Provider Manual
This form must be submitted within the week of hiring a new staff that will be providing direct therapy or be directly involved with any DSCYF/DPBHS youth entering services
Reportable Event (Incident) Form
This form is to be submitted for any qualifying Reportable Event as identified in the DSCYF Reportable Event Policy
Admission Summary Form
This form should be utilized by ALL providers who are not using the GAIN admission summary.
This assessment should be utilized by ALL providers who are not using the GAIN assessment.
This form should be utilized by ALL providers to summarize the treatment a client received
Medicaid Transportation Service Improvement Plan
This form should be utilized whenever there is a problem or concern related to LogistiCare services.
Mental Health and Substance Abuse Screen (EPSDT) - Directions
These are the directions for completing the Mental Health and Substance Abuse Screen (EPSDT)
Mental Health and Substance Abuse Screen (EPSDT) - Form
This is to be used by outpatient substance abuse and mental health providers to establish clinical eligibility for clients referred from sources other than DPBHS.
Mental Health and Substance Abuse Outpatient Discharge Form
This form is submitted by outpatient providers of mental health and substance abuse treatment within 30 days of discharge in order to obtain authorization for those clients with referral sources other than DPBHS.
Mental Health and Substance Abuse Outpatient Reauthorization Form
DPBHS initial authorization for outpatient clients who have referral sources other than DPBHS is or 20 sessions in the first year of treatment. This form is submitted to obtain further authorization.
Mental Health and Substance Abuse Outpatient Referral Form
This form is submitted by outpatient providers of mental health and substance abuse treatment in order to obtain authorization for those clients with referral sources other than DPBHS. See provider manual for authorization and submission instructions.
This is an overview of the Division’s philosophy on restraint and seclusion of clients
This is an optional format to utilize for the development of a client’s safety plan. Please be advised that there is a requirement to have a safety plan when appropriate.
Transfer Instruction Sheet
Although DSCYF Departmental Policy utilizes this form for any program providing residential or hospital services or instances when a client is being transferred to a residential facility from a community-based provider, effective July 1, 2011, the Division of Prevention and Behavioral Health Services began requiring ALL TREATMENT Service Providers to use this form at discharge from their agency. (Includes form, department policy and instructions for completing the form.)
Treatment Plan Form
This form should be utilized by ALL providers who are required to develop a treatment plan. This form can also be used for treatment plan updates; however, providers can develop their own format for updates if they prefer.
For more information pertaining to the GAIN Short Screener, please go to the GAIN Coordinating Center’s website at: http://www.gaincc.org/index.cfm?pageID=50
Human Resources Data Form
This form is referenced in the provider manual. All staff seeing children in crisis, intensive outpatient, routine outpatient, wrap-around, urgent response and free-standing day and part-day programs and all licensed clinicians who are seeing DPBHS clients or supervising staff who see clients in residential treatment, hospital or day hospital must submit this form via fax to (302) 622-4475 – Attention: DPBHS Program Administration Unit.
Reportable Events and Notification Procedures Provider Quick Reference
This is a synopsis of the incident reporting guidelines listed in the DSCYF Operating Guidelines.
Reportable Event (Incident) Form
Submission of this form is required for all incidents as described in the DSCYF Operating Guidelines. For cases involving DPBHS clients, the form should be faxed to the Quality Services Administrator at 1-302-661-7270.