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DMHMRSAS

Client Certification for Services

Agency: Name:________________________________________________________

Client No: ______________________________Client Date of Birth:______________

Initial Certification: ______________________or Recertification: ________________

To Be Eligible: Must have I and III and IV; OR I and II below
Box I Is age 18 or older; and
box II Is a Class Member (patient at AMHI on or after 1/1/88), or
box III Has a severe and disabling mental illness, defined as (must have either A or B; if B, must also have at least one of 1 through 8):

box  A. Axis I (DSM IV) classification of major mental illness in combination with sufficient severity of illness to cause disturbances in role performance or severe functional impairment.

Enter Qualifying Diagnosis: __________________________Dx #:______________

Source of Diagnosis:___________________________________________________

Note: Individuals with a concurrent substance abuse diagnosis may be included here: individuals whose only diagnosis is substance abuse are not eligible. Individuals with an Axis I adjustment disorder or a V code diagnosis are not considered to have a major mental illness, and therefore, do not meet this criterion.

box  B. Axis II (DSM IV) personality disorders.

Enter Qualifying Diagnosis: __________________ Dx#: ___________________

Source of Diagnosis: _________________________________________________

Individuals must meet the criteria for severe functional impairment by having at least one of the following psychiatric signs or symptoms:

box 1. Attempted or threatened suicide;
box 2. Confusion, disorientation, memory loss, or lack of judgement which impairs behavioral functioning;
box 3. Active hallucinations which impair behavioral functioning;
box 4. Delusional or disorganized thoughts which impair behavioral functioning;
box 5. Bizarre behavior with severe disturbances of mood and affect;
box 6. Severe psychomotor retardation, agitation, or hyperactivity;
box 7. Grossly inappropriate or grossly blunted affect;
box 8. Manifest inability to care for self, creating conditions either threatening to life or limb or likely to result in severe deterioration of medical condition(s).

AND

SPECIFIC REQUIREMENTS

IV. Must have at least one of A through J:

box A. Has been discharged from a psychiatric hospital, state mental institution or general hospital the last six months; or
box B. Has had a period of hospitalization for mental illness of at least six months' duration in the last eighteen months; or
box C. Has had two or more periods of hospitalization for mental illness in the last twelve months; or
box D. Has had four or more emergency face-to-face incidents with emergency mental health providers in last twelve months; or
box E. Is currently residing in a living arrangement financially supported by the Department of Mental Health, Mental Retardation and Substance Abuse Services; or
box F. Is homeless; or:
box G. Is in current crisis; or
box H. Is likely to deteriorate clinically to the point of needing immediate institutionalization in the absence of prompt community support services intervention; or
box I. Is currently receiving the medication Clozaril or its generic equivalent or will be receiving the medication in the next 30 days; or
box J. Has had a history of hospitalization for mental illness and a level of functional ability such that continued community support services are needed.

 

 

 

________________________________________________ _______________
         Signature of Person Making Determination         Date
 

________________________________________________
         Print Name and Title
 

05/15/00 9:19AM

  

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