CFTSS Request for Services Form : Children and Families : Who We Help : Abbott House

Today's Date

Month

Day

Year

Child's Name

First Name *

Middle

Last Name *

Date of Birth

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Medicaid/CIN #

Manage Care Company Name

Member ID#

Person Making Referral/Title/Relationship to Child

First Name *

Last Name *

Contact Number

Contact Email:

Referring Agency Name

Care Manager Name (if applicable):

First Name

Last Name

Agency Name:

Contact Number

Contact Email

Case Planner Name (if applicable):

First Name

Last Name

Agency Name:

Contact Email

Contact Number

Demographic Information for Child:

Child's Current Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Gender

Male
Female
Not Known

School Name:

School Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

If other please specify below

School Contact Name/Title

First Name

Middle

Last Name

School Contact Number:

Caregiver Information:

Name/Relationship to Child

First Name *

Last Name *

Primary Contact Number:

Second Contact Number:

Contact Email

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Is Medical Consenter same as Caregiver?

Yes
No (please complete below)

Medical Consenter Name:

First Name

Last Name

Relationship to Child:

Address

Country

Address Line 1

City

State/Province

Postal Code

Contact Number

Contact Email

Presenting Behaviors (Please Explain)

*Please Note*

Child must be Medicaid-eligible
Services requested must meet Medical Necessity Criteria
Must be recommended by an Other Licensed Practitioner (OLP)
Must have MCO authorization

Supporting Documentation

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CFTSS Services Requested

OLP (Other Licensed Practitioners) Medical Necessity
OLP Licensed Evaluation / Assessment
OLP Psychotherapy
OLP Crisis Interventions
CPST (Community Psychiatric Supports and Treatment)
Psychosocial Rehabilitation