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Extreme Counseling Solutions, Inc.
Referral For Mental Health Skill Building
Date of Birth:
Please select state.
District Of Columbia
Phone Number: (H)
Phone Number: (W)
Name of Other Providers:
Reason for Referral:
Brief family history/ Legal Involvement:
Type of Insurance (including Medicaid #):
Is the client currently residing in the home?
Are services able to be delivered in the client’s home?
Individual demonstrates a clinical necessity for this service arising from a condition due to mental, behavioral, or emotional illness which results in significant functional impairments in major life activities as evidenced by:
Individual meets at least two of the following criteria on a continuing or intermittent basis:
1. Has difficulty in establishing or maintaining normal interpersonal relationships to such a degree that he/she is at risk of hospitalization, homelessness, or isolation from social supports as evidenced by:
2. Requires help in basic living skills such as maintaining personal hygiene, preparing food and maintaining adequate nutrition or managing finances to such a degree that health or safety is jeopardized as evidenced by:
Health and Safety
Explanation must be provided:
3. Exhibits such inappropriate behavior that repeated interventions by the mental health, social service, or judicial systems are necessary as evidenced by:
4. Exhibits difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior as evidenced by: