Clinical Templates - Children's Services

The following files are in Microsoft Word template format.  Please download the file and save on it on your local computer for future use.

AB 3632  

• Discontinue Service
• Service Notification
• Utilization Form

Assessment Center  

• Intake
• Birth to 5 years old
• Ages 6 and older

CQRT Authorization  

• 0-5 Early Childhood Day Treatment Authorization
• Clinical/Quality Review
• Consumer Complaint Problem Resolution/Grievance Information
• Day Treatment Authorization Criteria
• Placement Authorization (rev. 4/05) (Instructions)
• RCL 13/14 Survey for Certification of Child

Initial Assessment  

• Youth
• Medication Support

Progress Notes  

• Case Management
• Day Intensive
• Day Rehabilitation Weekly Summary
• Guidance Clinic
• Medication Support
• Mental Health Services

Treatment Plan  

• Youth (Updated on 07/03/07)
• Medication Support

TBS     

• Initial Screening Criteria For TBS Eligibility (pdf)
• TBS Notice Policy (pdf)
• TBS Notice (MediCal Services for Children and Young People) (pdf)
• Receipt of TBS Notice

Community Functioning Evaluation (CFE)  

• Community Functioning Evaluation (CFE)
• Community Functioning Evaluation (0-5 Version)
• Community Functioning Evaluation (0-5 Version) Community Functioning Evaluation Key
• Community Functioning Evaluation (School Age Youth Version)
• Community Functioning Evaluation (School Age Youth Version) Instructions
• Community Functioning Evaluation (School Age Youth Version) Key

Other  

• Client Registration
• Discharge Summary
• Mandatory Abuse Report Form
• Beneficiary Death Report Form