Complete the following:

Date:

Client Name:

Client Insyst #:

Provider Name:

Reporting Unit:

Clinician:

Episode Opening Date:

Authorization Cycle:

Request for (check all that apply): 9. Mental Health Services:
Individual Psychotherapy	Frequency	and As Needed	Duration
Individual Rehabilitation	Frequency	and As Needed	Duration
Medication Services	Frequency	and As Needed	Duration
Case Management/Brokerage	Frequency	and As Needed	Duration
Family Psychotherapy	Frequency	and As Needed	Duration
Group Services
Family Collateral Group	Frequency	and As Needed	Duration
Multi-Family Therapy	Frequency	and As Needed	Duration
Psychotherapy Group	Frequency	and As Needed	Duration
Rehabilitation Group	Frequency	and As Needed	Duration
10. Day Treatment Services (check all that apply): Intensive: 5 Days/Week or Less Exceeds 5 Days/Week Initial 90 Days (3 months) Rehabilitative 5 Days/Week or Less Exceeds 5 Days/Week Initial 180 Days (6 months) Other
11. Discharge Readiness Criteria & Tentative Date:
12. Medical Necessity- (Medi-Cal Included Diagnosis; Support for Primary Diagnosis, Impairments to Functioning):
13. Focus of Treatment (Address Barriers to Lower Level of Care, Psychological issues, Risk (s) to Client or Others, Co-Occurring Issues etc.):
14. List Proposed Interventions (i.e. CBT, M.I., If a Risk has been identified include how these will be assessed and contained.):
15. Agency Clinician:	Recommended Approval: Yes No
Signature/Credentials
16. Agency Supervisor:	Recommended Approval: Yes No
Signature/Credentials
17. CQRT Reviewer:	Recommended Approval: Yes No (30 Day Return)
Signature/Credentials
18. Full Authorization - Start Date: End Date: 19. 30 Day Returns: 30 Day Authorization - Chart to be returned to CQRT: No Authorization - Chart to be returned to CQRT:
20. CQRT Chair Comments:
21. Chart to be returned to CQRT - Date: 22. CQRT Chair Signature/Credentials:__________________________________________________________________Date:________________