DEPARTMENT of BEHAVIORAL and DEVELOPMENTAL SERVICES
Adult Mental Health Services
MH 8/19/03
MaineCare Section 17 Client Certification Form
Part I. General Client/Agency Information
A. Agency Name: ________________________________________________________
B. Client Identification or Case No: __________________________________________
C. Client Date of Birth: ____________________________________________________
D. Initial Certification: _____________________ or Recertification: _______________
E. (Other): ______________________________________________________________
Part II. General Instructions:
A. A client certification form shall be completed for all clients receiving services from community support programs, which are funded in whole or in part by Adult Mental Health Services.
B. Eligibility and entry for services by community support programs funded in whole or in part by the BDS Adult Mental Health Services shall be restricted to those individuals who meet the requirements specified in this Client Certification for MaineCare Section 17 Services form.
C. Certification should be completed as part of the regular intake process of the agency.
D. Certification for individuals presently receiving community support services shall be completed on a schedule approved by the BDS Adult Mental Health Services.
E. A copy of the original and subsequent client certification shall be placed permanently in the client record.
F. All certified clients should be recertified for services every year.
G. For those clients for whom a waiver of certification requirements is requested, a completed certification form with clinical justification is to be directed to the Regional Team Leader.
Check all appropriate spaces that apply.
A client meets the specific eligibility requirements for covered services under Section 17 if:
o A. The person is a Class Member; (or)
o B. The person is age eighteen (18) or older or is an emancipated minor:
AND
o 1. Has a diagnosis on Axis I or Axis II of the multiaxial assessment system of the current version of the “Diagnostic and Statistical Manual of Mental Disorders”, other than one of the following diagnoses:
a. Delirium, dementia, amnestic, and other cognitive disorders;
b. Mental disorders due to a general medical condition, including neurological conditions and brain injuries;
c. Substance abuse or dependence;
d. Mental retardation;
e. Adjustment disorders;
f. V-codes; (or)
g. Antisocial personality disorders.
o 2. Has a score of 50 or below on the Global Assessment of Functioning (GAF) scale as determined by a professional licensed to assign a clinical diagnosis, and
o a. At least one of the following consequences resulting from signs and symptoms of the psychiatric diagnosis:
o i. has become homeless or at risk of losing his or her current residence (a person is homeless when he or she is without shelter or at serious risk of being without shelter, that is, when he or she lives in housing that is substandard, unaffordable, or life-threatening);
o ii. is causing repeated disturbances in the community because of poor judgment or bizarre, intrusive, or ineffective behavior;
o iii. is at great risk of arrest because of behavior which results from his or her psychiatric diagnoses, or is presently incarcerated because of such behavior;
o iv. presents a clear risk of harming self or others without community support services;
o v. manifests great difficulty in caring for self, posing a threat to his or her life or limb, without community support services; (or)
o vi. would deteriorate clinically to a point of needing immediate medical or psychiatric hospitalization in the absence of prompt community support services;
o b. The client meets the criteria for eligibility under Section 17.02-3(B) if, without current treatment or supportive services, he or she would clearly be exhibiting any of the difficulties described in Section 17.02-3(B)(2)(a)(i-vi) as a direct result of his or her Axis I or Axis II diagnosis and he or she would likely have a GAF score of less than 50 without current treatment or supportive services.
Part IV. DSM Diagnostic Classification
AXIS I Classification # ________ Classification described __________________________Date given: _________
AXIS II Classification # ________ Classification described _________________________Date given: __________
AXIS III Classification # ________ Classification described ________________________Date given: _________
AXIS IV Classification # ________ Classification described ________________________Date given: __________
AXIS V (GAF Score) ____________
Requesting agency signature: ________________________________________Date: ______________