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
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 form replaces both the CBRS Adult and Child Service Request Forms.
- 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