ST. CLAIR COUNTY COMMUNITY MENTAL HEALTH AUTHORITY BEHAVIOR TREATMENT PLAN REVIEW COMMITTEE REFERRAL FORM Recipient’s Name: Case Number: Primary Program: Residential Facility Name: Secondary Program: Case Holder’s Name: SECTION A: AUTHORIZATION Case Holder’s Signature: Date: Program Supervisor’s Approval/Signature: Date: Program Director’s Approval/Signature: Date: SECTION B: TYPE OF REFERRAL □ Aversive Technique □ Lethal Case Review □ Intrusive Technique Date of Death: □ Restrictive Technique Description: □ Clinical Consultation □ Token Economy/Response Cost Background Information: Description of Plan: SECTION C: REQUIRED MATERIALS FOR BTPRC REVIEW Aversive/Intrusive/Restrictive Techniques, Clinical Lethal Case Review: Consultations, and Token Economy/Response Cost □ Incident Report (attach copy) Reviews*: □ Death Report (attach copy) □ Behavioral Assessment (attach copy) □ Clinical Assessment (attach copy) □ IPOS (attach copy) and Proposed Intervention □ Medication Review (most recent; attach copy) □ Psychiatric Evaluation (most recent; attach copy)
ST. CLAIR COUNTY COMMUNITY MENTAL HEALTH AUTHORITY BEHAVIOR TREATMENT PLAN REVIEW COMMITTEE REFERRAL FORM Recipient’s Name: Case Number: Primary Program: Residential Facility Name: Secondary Program: Case Holder’s Name: SECTION A: AUTHORIZATION Case Holder’s Signature: Date: Program Supervisor’s Approval/Signature: Date: Program Director’s Approval/Signature: Date: SECTION B: TYPE OF REFERRAL □ Aversive Technique □ Intrusive Technique □ Restrictive Technique Description: □ Lethal Case Review Date of Death: □ Clinical Consultation Background Information: □ Token Economy/Response Cost Description of Plan: SECTION C: REQUIRED MATERIALS FOR BTPRC REVIEW Aversive/Intrusive/Restrictive Techniques, Clinical Consultations, and Token Economy/Response Cost Reviews*: □ Behavioral Assessment (attach copy) □ Clinical Assessment (attach copy) □ IPOS (attach copy) and Proposed Intervention □ Medication Review (most recent; attach copy) □ Psychiatric Evaluation (most recent; attach copy) Lethal Case Review: □ Incident Report (attach copy) □ Death Report (attach copy)
313%20BTPRC%20Referral%20Form%20(Handwritten).docx