Please check one of the boxes below: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy Early Childhood: Revised Edition (DC: 0-3R) (up to 48 months)
Diagnostic and Statistical Manual of Mental Disorders (DSM DSM-IV diagnostic tool can be sued for children ages 0- 5 years old)
Child’s current diagnoses with current severity.
Please describe the child’s symptoms that meet medical necessity and diagnostic criteria:
Please provide narrative (outcomes) of parent child observations and family assessment:
By signing below, I certify all the information I have provided concerning this child is correct and accurately reflects that Medicaid Treatment Child Care mental health services are medically necessary to treat psychosocial disorders of this child.