Service Request Forms
The following forms are for services requiring a pre-authorization. Please complete and submit the request before providing the service to a member.
Case Management Service Request Form
CBRS Adult Service Request Form
CBRS Child Service Request Form
Crisis Services Request Form
Extended Psychotherapy Service Request Form
Family Support Service Request Form
Initial Intensive Outpatient Program (IOP) Service Request Form
Continuing Intensive Outpatient Program (IOP) Service Request Form
Partial Care Service Request Form
Peer Support Service Request Form
Skills Building/CBRS Request Form This is a read only document. On July 1, 2018 the live version of the new Skills Building/CBRS Request Form will be available for provider use. Providers must use this form to request Skills Building/CBRS services. This form has options for Child and Adult within the same form.
Service Request Form Demo Video This video demonstrates how to fill out the new Service Request Form, using the Adult CBRS form for demonstration purposes. Please note that the video will play the most clearly on Firefox, or the newest version of Internet Browsers.
- Early Periodic Screening Diagnosis and Treatment Form (491.11 KB)
- Field Care Coordinator Referral Form 2018 (135.51 KB)
Global Distress Scale
The Optum Wellness Assessment is an integral part of the Idaho Clinical Model. Analyses demonstrate that the Wellness Assessment scales, comprised of items from well-validated public domain scales, are both valid and reliable. Both have been independently validated to ensure psychometric integrity as an outcome tool and to affirm the tool's use as an objective assessment tool with external credibility. Please reference a more detailed discussion of the Global Distress Scale, and its reliability and validity, for additional detail.
Provider Clinical Questions: (855) 202-0983 | PCP Psychiatric Consult press option 1