Client ID#: Primary Diagnosis: DD Diagnosis: Intake CGAS/GAF s1

A D A P T Medicaid/CMS Case Checklist BEHAVIORAL SERVICES

Client Name: DOB: Intake Date: Client ID#: Primary Diagnosis: DD Diagnosis: Intake CGAS/GAF: Problems: 1: 2: 3. 4. Intake Forms (all items in regular type must be turned into the office for a case to be opened) Client Information Sheet H2019-HR* Individual & Family Therapy Intake Consents form H2019-HO* TBOS-Therapy** No Show Policy H2019-HM TBOS-Behavior Management** PCP Notification H2019-HQ Group Therapy Release of Information (for case managers) H2017 Psychosocial Rehabilitation Bio-Psychosocial Evaluation H0031-HN Bio-Psychosocial Evaluation Progress Note for first session H0031 CFARS/FARS Client Rights Pamphlet (give to client/parent) H0032 Treatment Plan Health & Safety Pamphlet (give to client/parent) H0032-TS Treatment Plan Review/signed DC H2010-HO Brief Behavioral Health Status (LE) Children’s Functional Assessment Rating (CFARS) *requires Master’s degree Adult cases (age 18 and over) **TBOS limit 9hr/mo, only for under age 21 Functional Assessment Rating (FARS)

Medicaid Individual/Family limit TBOS/PsychRehab/>26 Individual-Family sessions Type (July 1-June 30) approval process AHCA 26 hours per year, firm TBOS: Clinical Supervisor approval Amerigroup No limit TBOS: Fax Amerigroup request form Cenpatico 26 hours per year TBOS/>26: Fax Cenpatico request form Magellan 26 hours per year, firm TBOS: Online request at MagellanProvider.com Psychcare 26 hours per year, firm TBOS: Fax Psychcare request form United No limit TBOS: Clinical Supervisor approval Wellcare 26 hours TBOS/>26: Fax Wellcare request form CMS No limit TBOS: Clinical Supervisor approval Session/units used tracking: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Date Date Follow-up Forms Due Date What’s due When due Date Done Licensed Evaluation 2 weeks after intake date Treatment Plan 1 month after intake date Treatment Plan Review 3 months after Intake date Extension approval by Clinical Supervisor 6 months after Intake date Treatment Plan Review (if extending past 6 months) CFARS (FARS for 18+) Extension approval by Clinical Supervisor 9 months after Intake date Treatment Plan Review (if extending past 9 months) Extension approval by Clinical Supervisor 12 months after Intake date Treatment Plan Review (if extending past 12 months) CFARS (FARS for 18+) Consents: Intake/No Show/Release Treatment Review for Discharge Within 15 days after last session if CFARS (FARS for 18+) planned discharge Consumer Discharge Rating Consumer Satisfaction Survey Treatment Review for Discharge Within 15 days after decision to discharge administratively Instructions: THIS IS FOR YOU TO KEEP. YOU CAN USE IT TO TRACK DUE DATES FOR THIS CASE

Revised 02/14

A D A P T Client Information Sheet BEHAVIORAL SERVICES DEMOGRAPHIC INFORMATION

Client First Name/Last Name: Social Security#: Birth Date: Age: Sex: Male Female Address: County: City: State: FL Zip: Email: Phone: Phone #2: Bilingual needed? no yes: School: Placement: Reg Ed Emotional/Behavioral Other Exceptional Ed Race: White Black Native American/Alaskan Asian Pacific Islander Multi-racial Ethnic: None Puerto Rican Mexican Cuban Other Hispanic Haitian Legal status: Minor Dependent Minor (foster home) Delinquent Minor Competent Adult Incompetent Adult FAMILY COMPOSITION Name Relationship Age Other Information

Other Parent/Guardian: Relationship: Phone: Address: email: OTHER CONTACTS Legal Guardian(s) Name/Relationship*: Phone: Emergency Contact Name/Relationship*: Phone: Referral Source: Name/Agency: Phone: Primary Care Physician: Name/Agency: Phone: Dependency Case Mgr: Name/Agency: Phone: Other Case Manager: Name/Agency: Phone: DJJ Worker/Probation Off: Name/Agency: Phone: Other MH Counseling: Name/Agency: Phone: Psychiatric/Medication: Name/Agency: Phone: School Contact: Name/Agency: Phone: Other: Name/Agency: Phone: *include address of guardian/emergency contact, if different from above: FUNDING Funding Type: Medicaid Healthy Kids Insurance FSPT CMS Other: Funding Agency:: Subscriber #: ADMINISTRATIVE INFORMATION

Primary Clinician Name: Intake Date: Client ID#: Primary Diagnosis Code: Developmental Disability Diagnosis Code: Intake GAF: Prior Adapt record(s) for this client filed in discharge year(s): Updated 06/12

A D A P T Intake Consents & Orientation BEHAVIORAL SERVICES

Client Name: Date of Birth:

______(initial) HEALTH & SAFETY: I received a copy of the Health & Safety pamphlet (red), and it was explained to me, including wellness education; the agency’s policies on tobacco, drugs, alcohol, prescription medications, weapons, abuse reporting, agency’s responsibility to respond to client risk of danger to self/others; the agency’s emergency procedures; and after hours crisis/emergency phone numbers.

______(initial) CLIENT RIGHTS: I received a copy of the Client Rights pamphlet (yellow), and it was explained to me, including what to expect in the assessment, treatment planning, treatment & discharge process; client rights & responsibilities; agency rights & responsibilities; grievance process; treatment philosophy; Primary Clinician name/phone number; and office hours/phone number.

______(initial) LIMITS TO CONFIDENTIALITY/PRIVACY: I understand that all information about the above-named client is considered private and will not be shared with anyone without my consent, except under the following circumstances:  Adapt is required to report suspicion of child/elder/disabled adults abuse & neglect.  Adapt is required to release information for the purpose of abuse/neglect investigations.  Adapt is allowed to warn potential victims if we believe that their lives are in danger.  Adapt is required to release a copy of records and/or testimony if subpoenaed in court. Even with your consent, Adapt will share only the information that is necessary for assessment, coordination of treatment, notification to those responsible for mandated treatment, or other specified purposes as described in the PCP Notification and Release of Information forms

______(initial) STATEMENT OF AUTHORITY TO CONSENT: I certify that I have the legal authority to consent to mental health treatment, release of information, and all legal issues involving the above-named client. If my status as legal guardian should change, I will immediately notify Adapt Behavioral Services of the name, address, and telephone number of the person who has assumed guardianship of the above- named client.

______(initial) CONSENT FOR TREATMENT AND TREATMENT LOCATION: I consent for the above- named client to participate in mental health assessment and treatment through Adapt Behavioral Services, including sharing relevant confidential information with those involved in services: School Personnel, such as teachers, counselors, behavior specialists, principal, etc. Other Family Members, such as step-parents, siblings, grandparents, foster parents, etc. Other Case Management or Treatment Professionals:

______(initial) FUNDING AUTHORIZATION: I authorize Adapt Behavioral Services to release relevant confidential information to my current funding source in order to process claims, obtain reimbursement, and comply with the funding source’s auditing requirements. **I understand that I will be responsible for any charges that this funding source does not cover, including any services provided after my insurance has lapsed, fees described on the Copayment Agreement, and fees described in the No Show/Cancellation Policy.

I understand that I may revoke consent for the above at anytime, however, I cannot revoke consent for action that has already been taken. A copy of this release shall be valid as the original. THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED.

______Client/Legal Guardian Signature Date Revised 11/12

A D A P T No Show/Cancellation Policy BEHAVIORAL SERVICES

Client: Date of Birth:

Regular attendance at scheduled appointments is very important. Our services will not be effective in helping you if you do not keep your appointments. Irregular attendance, especially a “no show,” is also inconvenient and costly for the staff assigned to help you. It is therefore your responsibility to attend all scheduled appointments.

CANCELLATION POLICY: If you call your assigned clinician at least an hour before your scheduled appointment, it is considered a “Cancellation,” although 24-hour notice is preferred. 1. After the first cancellation, the staff person will call you to reschedule. 2. After two cancellations in a row, the Director will send you a letter explaining that you must call him/her if you desire to continue services. 3. After the third cancellation in a row, services will be terminated. 4. If you cancel three times, with some attendance in between each cancellation, your therapist will discuss with you some possible solutions to the problem of irregular attendance.

NO SHOW POLICY: If you do not call to cancel at least an hour before the scheduled appointment time, it is considered a “No Show.” 1. If you fail to notify your assigned clinician prior to a missed in-home session, you will be charged a $10 travel fee to cover the staff cost of traveling to your home for the missed appointment. 2. If you fail to notify your assigned clinician prior to an in-office or in-school session, you may be charged a $10 travel fee if the staff traveled to that location specifically for that session. 3. After the first “No Show,” the staff person will call to reschedule the appointment. 4. After the second “No Show,” the Program Manager will send you a letter notifying you that services have been suspended and that you are required to pay the travel fees for both missed sessions in order to reinstate services. 5. After the third “No Show,” your case will be closed.

If these services are mandated or court-ordered, the person responsible for monitoring compliance with the mandate (e.g., dependency case manager, probation officer) will be notified of repeated cancellations/no shows and suspension or termination of services.

I understand Adapt Behavioral Service’s No Show/Cancellation policy and understand that regular attendance is necessary for treatment to be effective. Therefore, I agree to attend all scheduled sessions. If I cannot keep an appointment, I will call the staff 24 hours in advance to reschedule. If I have an emergency that prevents me from attending, I will call the assigned clinician at least one hour before the appointment to cancel.

______Client Signature Date

______Parent/Caregiver Signature Date Revised 11/12

A D A P T Primary Care Physician Notification BEHAVIORAL SERVICES

Client Name: Date of Birth:

This client’s Primary Care Physician is as follows: PCP Name: Mailing Address: City, State, Zip: Phone/Fax: Email address:

Purpose of Release: FOR NOTIFICATION PURPOSES ONLY -- DO NOT SEND RECORDS This document serves as notification to the Primary Care Physician that counseling and/or behavior analysis services are being provided by Adapt Behavioral Services: Intake date: Clinician Name: Clinician phone:

Acknowledgement: By signing below, I authorize Adapt Behavioral Services to release a copy of this document to the PCP named above. I further authorize exchange of confidential information between the PCP and Adapt Behavioral Services for the purpose of coordination of care. Contact information for Adapt Behavioral Services is as follows: Orange/Seminole/Lake: 225 S. Swoope Ave. #211, Maitland, FL 32751, (407) 622-0444 Volusia/Flagler/St. John’s: 533 N. Nova Rd. #204, Ormond Beach, FL 32174, (386) 898-5003 Osceola/Polk: 3483 W. Vine St., Kissimmee, FL 34741, (407) 928-0444

. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from Adapt Behavioral Services. . I understand that I may revoke this authorization in writing at any time, however I cannot revoke authorization for action that has already been taken. . A copy of this release shall be valid as the original.

THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.

______Client/Legal Guardian Signature Date

A D A P T Consent to Release Information BEHAVIORAL SERVICES

Client Name: Date of Birth: I authorize Adapt Behavioral Services Orange/Seminole/Lake Osceola/Polk Volusia/Flagler/St. Johns 225 S. Swoope Ave. #211 3483 W. Vine St. 533 N. Nova Rd. #204 Maitland, FL 32751 Kissimmee, FL 34741 Ormond Beach, FL 32174 (407) 622-0444 (407) 928-0444 (386) 898-5003 (407) 699-0444 fax (407) 518-0808 fax (386) 675-6490 fax to exchange confidential information concerning the above-named client with the following: Agency/Contact: Mailing Address: City, State, Zip: Phone/Fax: Email: I authorize: Informal communication regarding all client information between both parties. AND/OR Copies of the following documents to be mailed/faxed to the agency listed above Copies of the following documents to be mailed/faxed to Adapt Behavioral Services Limited verbal communication (no copies) related only to the following records (Check which documents are authorized to be released) Bio-Psychosocial Evaluation Psychiatric Evaluation Report Cards/Transcripts Licensed Evaluation Medication Management Behavioral Program Treatment Plan/Reviews Medical History & Physical Individual Education Plan Progress Summary Immunization Record Other: Discharge Review Lab Results Other:

Purpose of Release: Assessment Treatment Coordination Other, specify: Notification of compliance with court-ordered treatment (e.g., DCF, DJJ)

. I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Adapt Behavioral Services. . I understand that if I am court-ordered into treatment and refuse to allow Adapt Behavioral Services to share information with those responsible for monitoring my compliance with mandated treatment, this may result in negative consequences imposed by the court. . I understand that I may revoke this authorization in writing at any time, however I cannot revoke authorization for action that has already been taken. . A copy of this release shall be valid as the original. THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.

______Client/Legal Guardian Signature Date

A D A P T Bio-Psychosocial Evaluation BEHAVIORAL SERVICES

Client: Date of Birth: Age: Sex: Race: Primary Clinician: Intake Date: PSYCHOSOCIAL STRESSORS (circle descriptors or, if typing, delete descriptors that do not apply) Family changes: divorce/remarriage, death/birth, estranged, caregiver changes, other: Family conflict: between siblings, parent-child, couple/marital, extended family, other: Social/Relationships: lack of friends, peer conflict/rejection, death/loss of friend, other: Placement/Housing: crowded, moves, unsafe, homeless, risk of eviction/foreclosure, other: Educational: school changes, academic delays, poor grades, discipline, other: Financial/Work: low income, unemployed, supervisor conflict, retirement, other: Legal: protective services, arrest, incarceration, probation, litigation, police called, other: Disability/disorder: SSI, injury, chronic illness, physical limitation, developmental, other: Trauma/abuse: sexual abuse, physical abuse, foster care, crime victim, natural disaster, other: Current safety threat (written safety plan required): Other stressor: Describe: ______MEDICAL/PHYSICAL HISTORY Developmental history (children only): delays in crawling walking speech other: Immunizations up-to-date (children only): yes no, explain: Current & past medical issues (check all that apply & provide details below): none Seizure disorder Hypertension Gross motor problem Headaches Diabetes Heart problem Fine motor problem Stomach aches HIV/AIDS Kidney problem Prenatal drug exposure Bowel problem Brain injury Thyroid problem Life-threatening illness*** Allergies Paraplegia Vision impairment ***(requires safety plan) Asthma Dental problem Hearing impairment Other: Details: ______ADAPTIVE FUNCTIONING/STRENGTHS Self care skills: age-appropriate, verbal prompting, physical assistance, dependent, other: Communication level: age appropriate, articulation, nonverbal, speech delay, echoic, other: Intellectual/developmental abilities: IQ low/average/high, Autism/ASD, learning disability, other: Leisure/recreation interests: Support network/current resources: Client strengths: Family strengths: Other strengths: EDUCATIONAL HISTORY Highest grade completed: Learning/academic delays? Yes No Reading level? School performance: School behavior: Revised 10/13

A D A P T Bio-Psychosocial Evaluation – page 2 BEHAVIORAL SERVICES Client: EMPLOYMENT HISTORY Currently employed? Yes No Employer: Work performance/issues: BEHAVIORAL HEALTH/MENTAL STATUS (rating of 4+ requires intervention on MTP or rationale for omission) Severity: 1=no problem; 2-3=slight problem; 4-6=needs treatment; 7-9=hospitalization may be needed; P=past problem (>3 mo ago) Depression: sad, withdrawn, flat affect, hopeless, apathetic, lethargic, other: Anxiety: worries, fearful, phobic, panic, OCD, PTSD symptoms, sleepless, other: Hyper-manic: inattentive, disruptive, overactive, impulsive, distractible, sleepless, other: Psychosis: hallucinations, delusions, disoriented, loose associations, other: Substance use*: alcohol, tobacco, illegal, prescription, binges, cravings, other: Peer problems: argues, provokes, verbal abuse, physical aggression, rejected, other: Authority problems: defiant, argues, verbal abuse/cursing, physical aggression, other: Family conflict: conflict with sibling, parent, child, partner, extended family, other: Sexuality issues: sexual acting out, sexual preference issues, gender confusion, other: Self-care problems: poor hygiene, needs assistance, daytime enuresis, encopresis, other: Antisocial: breaks societal rules, lies, truant, curfew violations, firesetting, theft, other: Danger to self**: risk-taking, suicidal ideation/plan, self injury, suicide attempt, other: Danger to others**: violent, causes injury, weapons, homicidal ideation/threats, other: Sleep issues: resists bedtime, wakes frequently, wakes early, wets bed, other: Other symptom: Average hours sleep at night: *Rating of 7+ on substance use requires referral to substance abuse assessment/treatment **Rating of 7+ on danger to self or danger to others requires a written safety plan/crisis assessment Details & history of symptoms: ______SUICIDE RISK (based on clinical assessment--not to be conducted as a questionnaire) Passive thoughts (Client wishes he were…): None Past Current Frequency: Suicidal desire (Client wants to…): None Past Current Frequency: Suicidal intent (Client is going to…): None Past Current Recency: Suicide plan (How client is going to…): None Past Current Recency: Plan lethality (likelihood of death): None Low Moderate High Suicide means (Client has access to…): None Possible Likely Definite Risk Factors: NONE socially isolated recent/impending loss actively psychotic poor parent-child communication blames self for negative events gender identity struggles previous suicide gesture/attempt other self-destructive behavior family history of suicide chronic/painful medical condition history of physical/sexual abuse psychiatric hospitalization Assessed suicide risk: Low Moderate (on MTP) High (safety plan) Immediate (call 911) Details: ______Revised 10/13

A D A P T Bio-Psychosocial Evaluation – page 3 BEHAVIORAL SERVICES Client: MENTAL HEALTH TREATMENT HISTORY (include treatment type, provider/agency name, dates of treatment) Outpatient: Inpatient/crisis unit: Current psychotropic medications/dosages: Results/side effects of current medications: Prior medications/results/side effects: Prior diagnoses: Family mental health, substance abuse issues: Client has psychiatric advance directive? Yes No (if yes, attach a copy of written advance directive) Additional information: INTERPRETIVE SUMMARY (include significant findings in all areas, relationship between issues, factors affecting outcome) ______INITIAL TREATMENT PLAN Client statement of presenting issues: Client/family goals in treatment: Religious/cultural sensitive issues: Gender sensitive issues: Current services/social supports: Service recommendations/support needs: Client willingness to participate: Caregiver willingness to participate: Other preferences: PROVISIONAL DIAGNOSES (Clinical Impressions) Axis I: ICD-9: ICD-9: Axis II: ICD-9: Axis III: Axis V: GAF: Axis IV: Discussion of Diagnoses with Licensed Supervisor: Date: I agree with the treatment recommendations and provisional diagnoses contained in this evaluation.

______Primary Clinician/Credentials Date Completed Licensed Supervisor/Credentials Date Discussed Revised 10/13

A D A P T Progress Note BEHAVIORAL SERVICES Instructions: Write note within 24 hours after session. Turn in to office for filing in client record within 1 week.

Client Name: Date: Units of Service: Location: Start Time: am/ pm End Time: am/ pm SERVICE: TBOS-T (assessment; individual/family therapy; engagement of client’s support system; develop/implement/monitor behavior program) Individual & Family Therapy (insight oriented, cognitive behavioral, or supportive therapy to an individual or family--not school personnel) 90791-Intake Psychotherapy: 90834-45min OR 90837-60min Family Therapy: 90847-WITH client OR 90846-W/OUT client Assessment (FSPT-AS) In-Home & On-Site (FSPT-IHOS) Individual Outpatient (FSPT-IndOP) Funding ineligibility notification No show Cancellation Week without service (EXPLAIN) Other:

Problem #1: PROGRESS: Problem #2: PROGRESS: Problem #3: PROGRESS: Problem #4: PROGRESS:

PARTICIPANTS: Client Other(s): Relationship/Name PRESENTING ISSUES: INTERVENTIONS: ______

REFERRAL INFORMATION GIVEN FOR: Agency: Service Type: LEVEL OF PARTICIPATION/RESPONSE TO INTERVENTION: Client: Participation/response by other: Follow through on homework: PLAN: Next session scheduled for @ am/ pm. Homework assigned: Focus of next session: Signature: Name: Credentials: Date: Abbreviation Legend: Clt=client Tch=Teacher =increase =decrease mgmt=management Mx=mother SF=step-father Dx=diagnosis Tx=treatment +=positive wk=week GF=girlfriend Fx=father GM=grandmother Hx=history Bx=behavior x=times w/=with BF=boyfriend Revised 01/13

Client Name: Client ID#: Intake Date: Age: Instructions: Complete for all clients age 0-17 at admission, every 6 months & planned discharge

A D A P T BEHAVIORAL SERVICES Current Evaluation Date: Funder on date of evaluation: Medicaid plans: Healthy Kids plans: Other plans: 13=AHCA 60=Magellan-PMHP 23=Amerigroup HK 49=CMS 09=Amerigroup 95=Magellan-Trueheath 66=Magellan HK 59=Ped-I-Care 70=Cenpatico 65=Magellan-Wellcare 25=United HK 00=Private insurance 08=United 12=Psychcare Other: Other: 11=Magellan-CW Other: Purpose of Evaluation: 1=Admission 2=Every 6 months 3=Planned discharge No Minor Needs Hospitalization Children’s Functional Assessment Rating Scale (CFARS) prob problem outpatient may be treatment needed (for clients age 0-17) 1 2 3 4 5 6 7 8 9 Clinical Domains Depression: Depressed Mood, Sleep Problems, Sad, Hopeless, Withdrawn, Irritable, Lacks Energy/Interest, Anti-Depression Meds Anxiety: Anxious/Tense, Guilt, Phobic, Worried/Fearful, Anti-Anxiety Meds, Obsessive/Compulsive, Panic Hyperactivity: Manic, Inattentive, Agitated, Sleep Deficit, Overactive, Impulsivity, Mood Swings, Pressured Speech, Anti-Manic Meds, ADHD Meds Thought Process: Illogical, Delusional, Hallucinations, Paranoid, Ruminative, Derailed Thinking, Loose Association, Anti-Psychotic Meds, Disoriented Cognitive Performance: Poor Memory, Low Self-Awareness, Slow Processing, Attention/Concentration, Developmental Disability, Concrete Thinking, Impaired Judgment Medical/Physical: Acute Illness, Hypochondria, CNS Disorder Behavior, Chronic Illness, Need of Med/Dental Care, Pregnant, Poor Nutrition, Enuretic/Encoperetic, Eating Disorder, Seizures, Stress Related Illness Traumatic Stress: Acute, Dreams/Nightmares, Chronic, Detached, Avoidance, Repression/Amnesia, Upsetting memories, Hypervigilance Substance Use: Alcohol, Drugs, Dependence, Abuse, Over the Counter Drugs, Craving/Urge, DUI, Medical Control, Interferes with Functioning, IV Drugs Interpersonal Relationships: Poor Social Skills, Overly Shy, Problems with Friends, Difficulty Establishing./Maintaining Relationships Behavior in Home: Defies Authority, Disregards Rules, Conflict with Relative, Conflict with Parent/Caregiver, Conflict with Sibling/Peer ADL Functioning: Handicapped, Permanent Disability, Not Age Appropriate in: Communication, Self-Care, Hygiene, Mobility Socio-Legal: Disregards Rules/Norms, Offense to Property, Offense to Persons, Firesetting, Probation/Parole, Pending Charges, Dishonest/Lying, Gang member, Uses/Cons Others, Incompetent to Proceed, Detention/Commitment Work/School: Absenteeism, Skips Classes, Tardiness, Suspended, Dropped Out, Terminated/Expelled, Poor Performance, Learning Disability, Illiterate, Defies Authority, Disruptive Behaviors, Danger to Self: Suicidal Ideation, Current Plan, Recent Attempt, Past Attempt, Self- Injury, Risk Taking Behaviors, Serious Self-Neglect, Inability to Care for Self Danger to Others: Violent/Physically Aggressive, Threats, Causes Serious Injuries, Homicidal Ideation/Threats/Attempts, Uses Weapons, Cruelty to Animals, Sexual Assault Security/Management Needs: Suicide Watch, No Harm Contract, Locked Unit, Protection from Others, Seclusion, Home with Supervision, Run/Escape Risk, Restraint, Involuntary Exam, Time-out, Monitored House Arrest, One-to-One Supervision

Clinician Signature: ______Date:______Revised 09/13

______Signature/Credentials