Request for Ongoing Behavioral Health Services Form
Date of Request
*
-
Month
-
Day
Year
Member's GHC-SCW Number
*
Member's Name
*
First Name
Last Name
Member's Date of Birth
*
-
Month
-
Day
Year
Treating Provider
*
First Name
Last Name
Provider's Email Address
*
example@example.com
Provider NPI Number
*
Clinic Name
*
Clinic Tax ID Number
*
Phone Number
*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Service Type
*
Individual
Group
Couple
Family
Medication Management
Total Number of Sessions Provided
*
Additional Number of Visits Requested
*
Date Last Seen
*
-
Month
-
Day
Year
Date of Next Scheduled Visit
*
-
Month
-
Day
Year
Current Treatment Visit Frequency
*
ICD10 Code/DSM-5 Diagnosis
*
Anticipated Discharge Date/End of Treatment
*
-
Month
-
Day
Year
Current Information
Symptoms
*
Functional Impairments
*
Safety Concerns
*
Contributing Biopsychosocial Factors
*
Treatment modality/approach (e.g., Cognitive Behavior Therapy (CPT), Exposure Therapy, Dialectical Behavioral Therapy (DBT), etc.)
*
*
Measurable Treatment Goals
Number of Visits to Complete Goal
Document Progress Made Toward Goal
Medications
*
Other Behavioral Health Providers
*
Please upload all supporting clinical documentation to accompany this request:
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