ࡱ> prklmno%` U2bjbj"x"x "@@\!4&z&z&zhz{} ƆƆƆdvz$ h##6Y~ƍ`~~6ƆƆ~dƆƆ~z |,Ɔ} \d&z|j,02#^#,#,~~~~~~~66~~~~~~~9A8A STATE OF MAINE INTENSIVE TEMPORARY RESIDENTIAL TREATMENT  Dear Family/Legal Guardian(s), This letter explains our Intensive Temporary Residential Treatment application and authorization process. The attached application will be used to determine if your child is eligible for residential treatment. Your case manager or the OCFS (Office of Child and Family Services) staff will complete the application with you. They can also explain the process to you in more detail. If you need help locating a Case Manager, please let us know. If your child is in crisis and needs services immediately, please contact your local Crisis Team, your case manager or your local hospital/police department. The statewide Crisis Hotline number is 1-888-568-1112. When Is Intensive Temporary Residential Treatment Approved? Mental Health Treatment in Residential Facilities is used when your childs mental health needs cannot be served in your home or community. This generally happens when your child acts in unsafe ways or when needed treatment cannot be provided in your childs home and/or community. This treatment is for children who do not need hospital level of care. Mental Health Treatment in Residential Facilities is not meant to give a break or respite for parents or to be a long-term placement. If respite is needed, your childs treatment team should discuss what options may be available. What Are the Steps in the Approval Process? The first step in the approval process is to have a Family Team meeting. At that meeting, all treatment options will be explored by you and your team. This discussion will include risks and benefits of the various treatment services available. In addition, your childs case manager will contact the OCFS Mental Health Coordinator at this time. If residential treatment appears to be indicated, then the next step is to have the attached application completed and submitted to the OCFS Childrens Behavioral Health Services Regional office. Clinical documentation supporting the need for this treatment service must be submitted with the application. Next, the OCFS clinical staff reviews the application and the clinical documentation to determine if residential treatment is medically necessary for your child. If residential treatment is approved, it is important to remember that there are several residential treatment providers in Maine. Family and youth choice is very important in selecting a provider. There are providers that may be preferred; but there are reasons such as provider programs being full, specific types of treatment provided at a program, and ages of children at a program that may result in the need for another program. The family and youth team must consider more than one residential provider if the need for residential treatment is identified. You will get a copy of our decision. If you disagree with our decision, you will have the right to appeal the decision.  What Is The Family Expected to Do During Treatment? For your childs treatment to be effective, the immediate family must be actively involved in the ongoing treatment and care of your child. Extended family members may be asked to take part when appropriate, and with your permission. OCFS expects that the family will come to all family meetings and participate in treatment as the team determines appropriate. Treatment may include helping your child get ready for school or bed, help with homework or chores, etc. This gives the family a chance to practice what they have learned in therapy. Although rare, the Treatment Team may determine that there is a clinical reason why the family should delay involvement. What is the Family Expected to Pay for This Service? If your child gets Social Security or SSI benefits and is found eligible for residential treatment, you are required to use a portion of the Social Security or SSI money to help pay for the cost of the room and board. Please speak with your Social Security Office as soon as possible if your child will be entering residential treatment and let them know that your child will not be living in your home for a period of time. The residential treatment provider will also be following up with you about this piece if your child enters residential treatment. Adoption subsidies may also be impacted if this is applicable to your family. The subsidy may be suspended while your child is in treatment. Does My Child Need A Case Manager? We strongly suggest that the family have a Case Manager during your childs treatment. It is the role of the Case Manager to help with the discharge planning process and the transition of your child back into his/her community. If you need help finding a Case Manager call your local DHHS office and ask for Childrens Behavioral Health Services or visit our website at:  HYPERLINK "http://www.maine.gov/dhhs/ocfs/cbhs/index.shtml" http://www.maine.gov/dhhs/ocfs/cbhs/index.shtml. Sincerely, Child and Family Services Team APPLICATION FOR INTENSIVE TEMPORARY RESIDENTIAL TREATMENT  DEMOGRAPHICSMaineCare IDSoc. Sec. No.First NameLast NameDOBAge FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Address Use the child s HOME address, Do Not use Hospital, Detention or Residential addressCityStateZipCountyDistrict FORMTEXT       FORMTEXT       FORMTEXT ME FORMTEXT       FORMDROPDOWN  FORMDROPDOWN Guardian Name VERIFY LEGAL STATUSPhone Number and e-mail addressCo-guardian Name VERIFY LEGAL STATUSPhone Number and e-mail address FORMTEXT       Guardian Address:  FORMTEXT      Phone:  FORMTEXT       e-mail:  FORMTEXT       FORMTEXT       Co-guardian Address:  FORMTEXT      Phone:  FORMTEXT       e-mail:  FORMTEXT      Case Manager/Agency/AddressCase Manager Phone Number and e-mail addressCM Name: FORMTEXT       Agency:  FORMTEXT       CM Address:  FORMTEXT       CM City:  FORMTEXT       CM State:  FORMTEXT ME CM ZIP:  FORMTEXT       Phone:  FORMTEXT       E-mail:  FORMTEXT       Fax:  FORMTEXT      Other Parties to be notified by e-mail or FAX (no more than 2)Name:  FORMTEXT       Agency:  FORMTEXT       Phone:  FORMTEXT       e-mail address or FAX #:  FORMTEXT      Name:  FORMTEXT       Agency:  FORMTEXT       Phone:  FORMTEXT       e-mail address or FAX #::  FORMTEXT       Current Location:  FORMCHECKBOX  Home/Foster Home  FORMCHECKBOX  Hospital (name)  FORMDROPDOWN   FORMCHECKBOX Treatment Facility  FORMCHECKBOX  Mountain View/Long Creek  FORMCHECKBOX  Shelter  FORMCHECKBOX  Crisis Unit  FORMCHECKBOX  Other:  FORMTEXT      EDUCATIONCurrent School District Involve the school district PRIOR to submitting the application. ITRT funds do NOT cover education costs. School districts have processes required to follow and they appreciate early inclusion.  FORMTEXT      Special Education Identified? Note: if not Special Ed. identified, the school district is responsible for any educational components.  FORMCHECKBOX  Yes, the child has been given a Special Education primary disability type 1-16  FORMCHECKBOX  No If not, is there a 504 Plan?  FORMDROPDOWN Please include any documentation that describes any learning disabilities or cognitive impairments. Full Scale IQ  FORMTEXT    Current Funding SourcesPlease list the following sources of support/funding that are CURRENTLY associated with the child  FORMCHECKBOX Social Security Income Monthly Amount:  FORMTEXT       FORMCHECKBOX Adoption Subsidy Monthly Amount:  FORMTEXT       FORMCHECKBOX Private Insurance Carrier:  FORMTEXT       FORMCHECKBOX Other funding sources (Parental death benefits, trust funds, etc.) Describe:  FORMTEXT       Note: These sources are specific to the child, not other family members MEDICATIONSIs the child presently taking medications to address Mental Health Impairment?  FORMCHECKBOX  No Please provide documentation explaining reason child does not receive medication or if not indicated.  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page. ELIGIBILITY CRITERIA FOR LEVEL OF CAREAXIS I THROUGH V Diagnoses given within the past 6 months  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page.CAFAS , GAF, CHAT within the past 10 days  FORMCHECKBOX  Yes Please include assessment tool and refer to the REQUIRED DOCUMENTATION page.Even with intensive community intervention, including services and supports, there is Significant Potential That The Child Would Be Hospitalized or there is a clear indication that the childs condition would significantly Deteriorate And Would Require A Higher Level of service than can be provided in the home and community.  FORMCHECKBOX  No  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page. Does the child demonstrate a need for Therapeutic Treatment or Availability Of A Therapeutic On-Site Response On A 24 Hour Basis  FORMCHECKBOX  No  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page. Has the child displayed Significant Recent Aggression (within the past 2 months) across multiple environments or severe enough within one environment to have caused serious injury or there is significant potential of serious injury to self or others?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page. Has the child demonstrated Recent (within the past 2 months) HOMICIDAL IDEATION (including intent, plan and means) with risk of harm to self or others?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page. Has the child demonstrated Recent (within the past 2 months) SUICIDAL IDEATION (including intent, plan and means) with risk of harm to self?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page. Has the child demonstrated symptoms of mental illness, mental retardation, or pervasive developmental disorders that have resulted in the Inability To Care For Self To A Developmentally Appropriate Level, even with home and community supports?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Please include documentation referenced on the REQUIRED DOCUMENTATION page.  TREATMENT HISTORYPREVIOUS TREATMENT SERVICES IN PAST 12 MONTHSPlease review the following services and identify those which are currently provided and/or have been in the past 12 monthsSERVICESTARTENDINDIVIDUAL PROVIDER AND AGENCY AFFILIATION List provider agency along with name of individual providing service.FREQUENCYDISCHARGED AS PLANNED?Psychiatry/Med Mgt (Office based) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Outpatient Therapy (Office based) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Outpt. Family Therapy (Office based) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Psychiatric Hospital FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Crisis Unit FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Residential Treatment Program(s) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Multi-Systemic Therapy (MST) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Functional Family Therapy (FFT) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Home and Community Based Treatment (HCT) (NOT MST or FFT) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Assertive Community Treatment (ACT) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Rehabilitation and Community Services (RCS) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Intensive Outpatient FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FAMILY AND COMMUNITY INVOLVEMENT IN TREATMENTNote: It is the expectation of the Office of Child and Family Services that parents/caregivers will attend family therapy at least once weekly during their childs treatment, unless clinically contraindicated. Additionally, regular involvement is expected to occur, both at the treatment facility and in the childs home. Reasonable attempts will be made to support the caregiver in participating in their childs treatment. These reasonable attempts will include family team meetings with the youths team (including CBHS staff) with the goal of creating a plan to move past barriers preventing the caregiver from participating. The OCFS Protocol for Assisting Children at Risk may be utilized which includes bringing Child Welfare to the table as an added resource in an attempt to move beyond barriers to caregiver engagement. If the client is in states custody and has no identified caregiver, it is the expectation that the Child Welfare caseworker will participate fully in all treatment planning, and when a caregiver/natural support is identified, he/she will become involved in treatment as soon as possible.Plan to address permanency:  FORMTEXT      ANTICIPATED RISKS AND BENEFITS OF PROPOSED INTENSIVE TEMPORARY RESIDENTIAL TREATMENTRisksIntended BenefitsChildren may learn negative behaviors from peers Parent and child relationship may be disrupted Children frequently detach from their families or significant caregivers Child will not be in a typical family/community environment. Families may have difficulty meeting the required family therapy expectations Families may have difficulty integrating child into the home Children may feel rejected or abandoned Children may not be able to use skills learned in program once at home or less restrictive setting Treatment may not be effective Families receiving SSI, TANF, housing assistance or other financial aid may see a reduction on benefits during the residential treatment Other risks specific to this child:  FORMTEXT      Children learn positive behaviors from peers or staff at program Parent and child bond strengthen as a result of family therapy Children and families/significant caregivers working together in family therapy will result in better behaviors on returning home/less restrictive environment Children will be in a safe environment Children will learn greater self-regulation Other benefits specific to this child:   FORMTEXT      PARENTAL NOTIFICATION OF CONDITIONS OF FUNDINGPlease initial after each section and sign below in Parent/Guardian Section:I agree that my child will return home when treatment related to the reason for admission to residential treatment is completed, and when appropriate mental health services are in place for my childs return home. _____ ______ I agree to be actively involved in my child's treatment which includes family meetings, family therapies, and if indicated, home visits for my child. My signature below indicates my willingness to participate in the treatment process, and my agreement that treatment will focus on the return of my child home. _____ ______ I agree to maintain parental involvement while my child is in treatment. This includes being an active part of my childs life and daily activities (i.e. homework, behavior management practice, chores, laundry, etc.) beginning the first week my child is in treatment, unless clinically contraindicated. _____ ______ I agree to the release of the information contained within this application, and that it may be released to the receiving facility as part of the treatment planning process. _____ ______ I agree to disclose all information regarding alternative funding sources, such as adoption assistance, Social Security, Private Insurance, and any other funding sources that may be available to my child. _____ ______ I agree that the State of Maine Department of Health and Human Services, Office of Child and Family Services may use these funds to offset the State's share of providing this service. _____ ______ I agree to allow the Department of Health and Human Services to share information within its offices, its contracted agents, and with the Departments of Corrections and Education all matters directly related to the treatment of my child. _______ ______ I have read and understand the above risks and benefits as they have been outlined. 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H 6`0i+4 lanZpZ [w$$&`#$/Ifa$wkdf$$Ifl[*i+   6` 0i+4 lap  [ [p\]^_`fahb0c1cr $&`#$/If & F2$&`#$/Ifnkdqg$$Ifl^*i+  6`0i+4 lap 1c2c3c4cUcccdddd}enoyyyytt$a$$xa$ x-DM nkd)h$$Iflu*i+   6`0i+4 lap or the Office of Child and Family Services to authorize treatment in a residential treatment facility, it is necessary to submit clinical documentation that supports the child meeting the medical eligibility criteria listed in MaineCare Benefits Manual Chapter II Section 97.02, Child and Adolescent Intensive Behavioral Health Treatment in a Residential Setting. 1.) It is required that the case manager/caseworker discuss with the youth and guardian that it is STRONGLY ENCOURAGED to include the following within your submitted documentation: Youth Voice/Perspective on current behaviors and what the youth thinks would help This can be a something written by the youth or progress notes/team meeting notes in which the youth voice is captured. Caregiver/Guardian Perspective on current behaviors and what the guardian thinks would help This can be a written narrative by the guardian or progress notes/team meeting notes in which the guardian perspective is captured. 2.) The following is REQUIRED DOCUMENTATION to be submitted with the application: **For purposes of this document, Treatment Progress Notes or Treatment Summary is defined as having all of the following parts: Clearly demonstrate presenting behavior (frequency, intensity and duration) Documents where and under what conditions the behaviors occur Documents whether or not there are any intellectual impairments that impact treatment Clinical modalities/interventions being used and what is currently recommended What is working What are the barriers to treatment efficacy What is the current plan based on the presenting behaviors If the child is on medications for symptoms related to behaviors/mental health, please submit the following: Current prescribing practitioner notes that include what medications the child is on currently on (dose, frequency, what its being used for and date started) other medications tried in the past 6 months PRN use if applies Any significant information to know regarding medication management An Axis I - V Diagnosis from the most current version of the DSM Documented by a licensed clinician Documented within the last 6 months Examples of documentation may be evaluations or assessments (psychiatric, psychological, LCSW assessment(s), etc.) CAFAS, CHAT and/or GAF justified within 10 days of application submission to OCFS CAFAS and CHAT Entire scoring tool with Rater ID number of person who completed the tool GAF Score with a description of the indicators used to come up with the score done by an appropriately credentialed clinician  Documentation that even with intensive community intervention, including services and supports, there is significant potential that the child will be hospitalized, or there is a clear indication that the childs condition would significantly deteriorate and would require a higher level of service than can be provided in the home and community. Please include: Treatment progress notes/treatment summary and/or incident reports from clinician working with child in past 2 months demonstrating unsafe behavior. Mobile Crisis assessments Documentation of a current need for therapeutic treatment or availability of a therapeutic on-site staff response on a 24 hour basis. Please include: Treatment progress notes/treatment summary from clinician working with child in past 2 months that includes all of the following: Clearly demonstrate presenting behavior (frequency, intensity and duration) Documents where and under what conditions the behaviors occur Documents whether or not there are any intellectual impairments that impact treatment Clinical modalities/interventions being used and what is currently recommended What is working What are the barriers to treatment efficacy What is the current plan based on the presenting behaviors Treatment progress notes/treatment summary or significant incident reports from all service providers (include hospital and crisis services) within the last 6 months. This may be the same as the documentation within the last 2 months referenced below depending on if the child has had other providers when looking back 6 months. List of services the child and family has received over the past 12 months (if this is included in the actual application then do not duplicate with this) Clinical documentation of unsafe behaviors occurring within the past 2 months Treatment progress notes/treatment summary regarding the past 2 months from any/all clinician(s) working with child that includes all of the following: Clearly demonstrates presenting behavior (frequency, intensity and duration) Clearly demonstrates inability to care for oneself to a developmentally appropriate level if applicable Documents where and under what conditions the behaviors occur Documents whether or not there are any intellectual impairments that impact treatment Clinical modalities/interventions being used and what is currently recommended What is working What are the barriers to treatment efficacy What is the current plan based on the presenting behaviors Any Incident Reports or Crisis Assessments occurring within the past 2 months (could be from police, crisis, hospital, current/past providers, school, animal control, fire department, etc.) with outcome/next steps after incident included If the youth is receiving the Wraparound Maine Service, the Guidelines for Wraparound Maine Teams for Intensive Temporary Residential Treatment must be utilized along with the required documentation listed above. 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