Over the Counter Medications Alcohol Use/Abuse Illicit Drug Prescription Drug Use/Abuse 27A) Treatment and Service History information regarding co-occurring mental health and substance abuse disorders: — Date of assessment for co-occurring disorders: Have you communicated with the Member’s PCP to Is member receiving integrated MH/SA coordinate mental health and physical health care? services? (Indicate with N, Y): (Indicate with N, Y, or N/A): How long has member been receiving this service: How many times has the member been seen by your Currently on service within this authorization period: probation/parole/conditional release? (Indicate with N, Y): 27B) Frequency indicate the number of occurrences by placing an in the appropriate box for each category: – “X” Category 0 1-2 times 3-4 times 5 or more times Number of inpatient admissions in the last 12 months Number of ER or other crisis episodes in the last 12 months Number of years of active mental health treatment Number of lifetime homeless episodes Number of lifetime jail/prison terms
Over the Counter Medications Alcohol Use/Abuse Illicit Drug Prescription Drug Use/Abuse 27A) Treatment and Service History — information regarding co-occurring mental health and substance abuse disorders: Date of assessment for co-occurring disorders: Have you communicated with the Member’s PCP to coordinate mental health and physical health care? (Indicate with N, Y, or N/A): Is member receiving integrated MH/SA services? (Indicate with N, Y): How long has member been receiving this service: How many times has the member been seen by your service within this authorization period: Currently on probation/parole/conditional release? (Indicate with N, Y): 27B) Frequency – indicate the number of occurrences by placing an “X” in the appropriate box for each category: Category 0 1-2 times 3-4 times 5 or more times Number of inpatient admissions in the last 12 months Number of ER or other crisis episodes in the last 12 months Number of years of active mental health treatment Number of lifetime homeless episodes Number of lifetime jail/prison terms
ME_Section_65_Suggested_ITP_Template.docx