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BEHAVIORAL  HEALTH LOB: QUEST   ACAP  

                                             Service  Type:     MH       CD Dual  DX                                                Auth  Request  Type:   Standard Retro  

1. Provider/Facility:______________________________________

   Contact  Person:_______________________________________  

Big  Island   Maui    Oahu  

Molokai   Kauai   Lanai  

Phone:   Fax:   Request  Date:  

2.   2. Member  Name:____________________________________________    Member  ID:_______________________    DOB:______/_____/_________  Age:________  __

3. DSM/ICD  10  Diagnostic  Codes:

                         Primary:___________________________________________________  

                         Secondary:_________________________________________________  

   _________________________________________________________  

4. Medical  Conditions:

________________________________________________________________  

5. Z  Codes:  Please  check  areas  of  concern  (if  applicable):

Primary  Support  Group     Legal  System/Crime   Housing     Economic  Social  Environment       Occupational       Access  to  Care       Educational                

Other:_________________________________________________________  

7. Requested  #  of  Sessions:_______________________________________

From:_________________  _________To:___________________________  

8. Required  Documentation:    Please  submit  required  clinical  notes  for  either  6A  or  6Bas  listed  below:  

A. Outpatient  Mental  Health:     Clinical  Summary     Behavioral  Contract  (If  applicable)  

B. Chemical  Dependency/Dual  Diagnosis:   UA  results     Behavioral  Contract  (If  applicable)  

9. If  this  is  a  Retro-­‐request  please  explain  why:      ___________________________

____________________________________________________________________  

6. Level  of  Care  Requested:

Social  Detox     Res     PHP     IOP     LIOP     OPS Methadone  Maintenance  

8.   10. Current  Medications:    (psychiatric/other)

Medication   Dose   Frequency   Start  Date   Prescriber  

     CONTINUING  MENTAL  HEALTH  OUTPATIENT  AND/OR  CHEMICAL  DEPENDENCY  PRIOR  AUTH  REQUEST  FORM

April 2016

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         Does  member  require  an  Interpreter?   Yes       No              If  yes,  what  language  :    ___________________________________________________________________________  

Is  Care  Coordination  requested:     Yes   No        (If  yes,  please  explain):___________________________________________________________________________________  

QUEST  only:    Potential  SMI/SPMI/SEBD:     Yes   No    

CLINICAL  INFORMATION:    (Please  complete  the  following)  

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

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Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

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Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

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Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date  of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

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Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date  of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________  

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

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Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________  

4. Is  member  on  a  Behavior  Contract? Yes   No      If  yes,  please  explain  why  and  attach  a  copy:  

____________________________________________________________________________________________________________________________________  

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

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Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does  member  attend  any  sober  support  meetings? Yes   No  

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________  

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community?  __________________________________________________  

____________________________________________________________________________________________________________________________________  

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does  member  have  a  sponsor? Yes   No          If  yes,  How  many  contacts  per  week?_______________________________________________________________  

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

April 2016 Page 2 of 8

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL  INFORMATION:    (Please  complete  the  following)  

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member  attend  all  scheduled  sessions?     Yes       No        If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does  member  have  a  sponsor? Yes   No          If  yes,  How  many  contacts  per  week?_______________________________________________________________  

7. Is  member  working  on  the  12  Steps? Yes   No          If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member  working  on  the  12  Steps? Yes   No          If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does  member  have  a  Sober  Support  Phone  Tree? Yes   No  

If  yes,  how  many  #’s  collected?____________________________  How  often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is  member  able  to  take  feedback  w/o  taking  offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

April 2016 Page 3 of 8

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is  member  able  to  take  feedback  w/o  taking  offense?__________________________________________________________________________________________

12. Any  Significant  insight/connections  made?    Any  Behavior  Changes? Yes   No        If  yes,  please  explain:_______________________________________________  

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

10. Is  member  able  to  give  feedback  w/o  being  hurtful?    __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL  INFORMATION:    (Please  complete  the  following)  

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________  

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned coping  skills?  What  skills? Please explain:__________________________________________________________________________________

April 2016

Page  2  of  6

Does member require an Interpreter?   Yes No If  yes,  what  language  : ___________________________________________________________________________

Is  Care  Coordination  requested: Yes No  (If yes, please  explain):___________________________________________________________________________________

QUEST  only:    Potential  SMI/SPMI/SEBD: Yes No

CLINICAL INFORMATION: (Please  complete  the  following)

1. Please  explain  why  member  continues  to  require  this  Level  of  Care:______________________________________________________________________________

_____________________________________________________________________________________________________________________________________

2. Did  member attend  all scheduled  sessions? Yes No If  No,  please  list    dates  and  reasons  for  non-­‐attendance:______________________________________

_____________________________________________________________________________________________________________________________________

3. Date of  most  recent  UA:___________________________________Results:________________________________________________________________________

If  UA  was  not  done,  please  explain  why:____________________________________________________________________________________________________

4. Is member on  a Behavior Contract? Yes No If  yes,  please  explain  why  and  attach  a  copy:

____________________________________________________________________________________________________________________________________

5. Does member attend  any sober support meetings? Yes No

If  yes,  how  many  meeting  per  week:_______________________________________________________________________________________________________

If  No,  what  is  your  plan  to  assist  member  in  connecting  to  a  sober  support  system  in  the  community? __________________________________________________

____________________________________________________________________________________________________________________________________

6. Does member have a  sponsor? Yes No If  yes,  How  many  contacts  per  week?_______________________________________________________________

7. Is  member working on  the 12 Steps? Yes No If  yes,  What  step  is  member  on?______________________________________________________________  

8. Does member have a  Sober Support Phone Tree? Yes No

If  yes,  how  many  #’s  collected?____________________________ How often  used?_________________________________________________________________  

9. What  is  member’s  current  assignment?_____________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

10. Is  member  able  to  give  feedback  w/o  being  hurtful? __________________________________________________________________________________________

11. Is member able  to take  feedback w/o taking offense?__________________________________________________________________________________________

12. Any  Significant insight/connections made? Any Behavior Changes? Yes No        If  yes,  please  explain:_______________________________________________

13. Has  member  learned  coping  skills?  What  skills?    Please  explain:__________________________________________________________________________________

April 2016

April 2016 Page 4 of 8

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Page  3 of  3

 ASAM  DIMENSIONS  (please  explain  all  medium  and  high  ratings)  1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC DATE  OF  

REQUESTSESSIONS START  DATE END DATE TX  PLAN

DUE DATETCDUE DATE

AUTH  # CRITERIA  USED

APPROVED: YES   NO   PARTIAL DATE  OF  DECISION:   Reviewers signature____________________________ MD    Signature:__________________________________

1357  Kapiolani  Blvd.,  Ste.  1250,  Honolulu,  HI 96814. BH Phone: 973-­‐2475  (Oahu) or 1-­‐888-­‐875-­‐4979  (NI).        BH  FAX:  973-­‐6324  or 1-­‐800-­‐293-­‐4580  

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580

EXPLAIN

Page  3 of  3

ASAM DIMENSIONS (please explain  all medium and  high  ratings)1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC DATE  OF  

REQUESTSESSIONS START  DATE END DATE TX  PLAN

DUE DATETCDUE DATE

AUTH  # CRITERIA  USED

APPROVED: YES   NO   PARTIAL DATE  OF  DECISION:   Reviewers signature____________________________ MD    Signature:__________________________________

1357  Kapiolani  Blvd.,  Ste.  1250,  Honolulu,  HI  96814.    BH  Phone:  973-­‐2475  (Oahu)  or  1-­‐888-­‐875-­‐4979  (NI).        BH  FAX:  973-­‐6324  or  1-­‐800-­‐293-­‐4580  

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580

April 2016 Page 5 of 8

• Any current physical illness (besides withdrawal) that may impact course of treatment?• Is member pregnant?

2. Biomedical Conditions & Complications HIGHLOW MED

Yes No

• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?

EXPLAIN

1. Alcohol Intox. And/or Withdrawal Potential HIGHLOW MED

Page  3 of  3

 ASAM  DIMENSIONS  (please  explain  all  medium  and  high  ratings)  1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC DATE  OF  

REQUESTSESSIONS START  DATE END DATE TX  PLAN

DUE DATETCDUE DATE

AUTH  # CRITERIA  USED

APPROVED: YES   NO   PARTIAL DATE  OF  DECISION:   Reviewers signature____________________________ MD    Signature:__________________________________

1357  Kapiolani  Blvd.,  Ste.  1250,  Honolulu,  HI 96814. BH Phone: 973-­‐2475  (Oahu) or 1-­‐888-­‐875-­‐4979  (NI).        BH  FAX:  973-­‐6324  or 1-­‐800-­‐293-­‐4580  

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580

EXPLAIN

EXPLAIN

Page  3 of  3

ASAM DIMENSIONS (please explain  all medium and  high  ratings)1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC DATE  OF  

REQUESTSESSIONS START  DATE END DATE TX  PLAN

DUE DATETCDUE DATE

AUTH  # CRITERIA  USED

APPROVED: YES   NO   PARTIAL DATE  OF  DECISION:   Reviewers signature____________________________ MD    Signature:__________________________________

1357  Kapiolani  Blvd.,  Ste.  1250,  Honolulu,  HI  96814.    BH  Phone:  973-­‐2475  (Oahu)  or  1-­‐888-­‐875-­‐4979  (NI).        BH  FAX:  973-­‐6324  or  1-­‐800-­‐293-­‐4580  

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580

April 2016 Page 6 of 8

• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?

4. Readiness to Change (Treatment Acceptance/Resistance) HIGHLOW MED

• Any psych. Illness or psychological, behavioral, or emotional problems that may impact the course of treatment?3. Emotional/ Behavioral or Cognitive Conditions & Complications HIGHLOW MED

Page  3 of  3

 ASAM  DIMENSIONS  (please  explain  all  medium  and  high  ratings)  1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC DATE  OF  

REQUESTSESSIONS START  DATE END DATE TX  PLAN

DUE DATETCDUE DATE

AUTH  # CRITERIA  USED

APPROVED: YES   NO   PARTIAL DATE  OF  DECISION:   Reviewers signature____________________________ MD    Signature:__________________________________

1357  Kapiolani  Blvd.,  Ste.  1250,  Honolulu,  HI 96814. BH Phone: 973-­‐2475  (Oahu) or 1-­‐888-­‐875-­‐4979  (NI).        BH  FAX:  973-­‐6324  or 1-­‐800-­‐293-­‐4580  

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580

EXPLAIN

EXPLAIN

Provider Signature: _____________________________Date:___________________

• Does the member have supportive friendships, financial, educational, or vocational resources that will increase the likelihood of successful TX?

• Are there family members, significant others, living situations, or school/work situations that pose a threat to TX engagement and success?

6. Recovery Environment HIGHLOW MED

• Is the member in immediate danger of continued severe distress, and drinking/drug behavior?

• Does the member have any understanding of, or skills in which to cope with his/her addiction problems in order to prevent relapse/continued use?

5. Relapse (Continued Use Potential) HIGHLOW MED

April 2016

Page  3 of  3

ASAM DIMENSIONS (please explain  all medium and  high  ratings)1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC DATE  OF  

REQUESTSESSIONS START  DATE END DATE TX  PLAN

DUE DATETCDUE DATE

AUTH  # CRITERIA  USED

APPROVED: YES   NO   PARTIAL DATE  OF  DECISION:   Reviewers signature____________________________ MD    Signature:__________________________________

1357  Kapiolani  Blvd.,  Ste.  1250,  Honolulu,  HI  96814.    BH  Phone:  973-­‐2475  (Oahu)  or  1-­‐888-­‐875-­‐4979  (NI).        BH  FAX:  973-­‐6324  or  1-­‐800-­‐293-­‐4580  

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580Page 7 of 8

Page  3 of  3

ASAM DIMENSIONS (please explain  all medium and  high  ratings)1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC   DATE  OF  

REQUEST  SESSIONS   START  DATE   END  DATE   TX  PLAN  

DUE  DATE  TC  DUE  DATE  

AUTH  #   CRITERIA  USED  

   APPROVED:   YES   NO     PARTIAL          DATE  OF  DECISION:        Reviewers  signature____________________________    MD    Signature:__________________________________  

1357  Kapiolani  Blvd.,  Ste.  1250,  Honolulu,  HI  96814.    BH  Phone:  973-­‐2475  (Oahu)  or  1-­‐888-­‐875-­‐4979  (NI).        BH  FAX:  973-­‐6324  or  1-­‐800-­‐293-­‐4580  

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580

LEVEL OF CARE DETERMINATION: ** FOR AC Use Only

Page  3 of  3

ASAM DIMENSIONS (please explain  all medium and  high  ratings)1. Alcohol Intox. And/or Withdrawal Potential

• Any  risk  of  severe  withdrawal/seizures?• Any current signs of withdrawal?

LOW MED HIGH EXPLAIN

2. Biomedical Conditions & Complications• Any  current  physical  illness  (besides  withdrawal)  that may

impact course of treatment?• Is member pregnant?   Yes No

3. Emotional/ Behavioral or Cognitive   Conditions & Complications• Any  psych.  Illness  or  psychological,  behavioral,  or  emotional

problems that may impact the  course  of treatment?4. Readiness to Change  (Treatment Acceptance/Resistance)

• Is the member  objecting/resistant  to treatment?• What  is  the  member’s  readiness  to  change?

5. Relapse  (Continued Use  Potential)• Is  the  member  in  immediate  danger  of  continued  severe

distress, and  drinking/drug behavior?• Does the member have any understanding of, or skills in

which  to  cope with his/her addiction  problems in  order toprevent relapse/continued  use?

6. Recovery Environment• Are  there  family  members,  significant  others,  living

situations, or school/work situations that pose a threat to  TXengagement and success?

• Does the member have supportive friendships, financial,educational, or vocational resources that will increase  thelikelihood  of successful TX?

Provider Signature: ______________________________________Date:_______________________

LEVEL  OF  CARE  DETERMINATION:    **For  AC  Use  onlyLOC DATE  OF  

REQUESTSESSIONS START  DATE END DATE TX  PLAN

DUE DATETCDUE DATE

AUTH  # CRITERIA  USED

APPROVED: YES   NO   PARTIAL DATE  OF  DECISION:   Reviewers signature____________________________ MD    Signature:__________________________________

 

April 2016 Page 3 of 3

1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580

April 2016 Page 8 of 8