Clinical Templates - Children's Services

The following files are in Microsoft Word template or PDF format. 
Please download the file and save on it on your local computer for future use.

AB 3632  

• Discontinue Service
• Service Notification
• Utilization Form

Initial Assessment  

• Ages 0-5
• Ages 6-10
• Ages 11-17

Worksheets   

• ACBH SMHS Outpatient Medi-Cal Included List by DSM-5 Name
• ACBH SMHS Outpatient Medi-Cal Included Crosswalk
• GMC Codes
• ACBHCS Psychosocial Conditions by DSM Name

Assessment Center (non Medi-Cal Mental Health Screening);   

• Intake
• Ages 0-5
• Ages 6 and older

CQRT Authorization  

• 0-5 Early Childhood Day Treatment Authorization
• Clinical/Quality Review
• Consumer Complaint Problem Resolution/Grievance Information
• Day Treatment Authorization Criteria
• Placement Authorization (rev. 4/05) (Instructions)
• RCL 13/14 Survey for Certification of Child

Medication Support  

• Sample Medi-Cal Compliant Psychiatric Mental Health Assessment:  PDF    Word
• Sample Medi-Cal Compliant Psychiatric Mental Health Client Plan:  PDF    Word

Progress Notes  

• Sample Medi-Cal Compliant Outpatient MH Progress Note:   PDF   Word
• Non-Medi-Cal Compliant Case Management
• Day Intensive
• Day Rehabilitation Weekly Summary
• Guidance Clinic
• Medication Support
• Non-Medi-Cal Compliant Mental Health Services

Treatment Plan  

• Sample Medi-Cal Compliant MH Treatment Plan:   PDF   Word
• Medication Support - Forthcoming

TBS     

• Initial Screening Criteria For TBS Eligibility (pdf)
• TBS Brochure (pdf)
• TBS Notice Policy (pdf)
• TBS Notice (MediCal Services for Children and Young People) (pdf)
• Receipt of TBS Notice

Community Functioning Evaluation (CFE)  

• Community Functioning Evaluation (CFE)
• Community Functioning Evaluation (0-5 Version)
• Community Functioning Evaluation (0-5 Version) Community Functioning Evaluation Key
• Community Functioning Evaluation (School Age Youth Version)
• Community Functioning Evaluation (School Age Youth Version) Instructions
• Community Functioning Evaluation (School Age Youth Version) Key

Other  

• Client Registration
• Discharge Summary
• Mandatory Abuse Report Form
• Beneficiary Death Report Form
• Medication Consent Forms