Maine DHHS - Questionnaire - Child Inpatient

Status: Incomplete

1. Does the member exhibit an immediate or direct threat of serious harm to self or there is a clear and reasonable inference of serious harm to self, where suicidal precautions or observations are required twenty four hours per day?

(Please select one.)

2. What are the required intensive interventions on a 24-hour day basis in the last review period:

(Please select one.)

3. What are the symptoms/behaviors that are of such severity that they require 24-hour/day intensive medical, psychiatric, and nursing services.

4. Is a lower level of care available?

(Please select one.)

5. Describe the guardian(s) active participation since the last authorization review period:

6. Has guardian attended coordination meetings?

(Please select one.)

Instructions: Please include phone call and email attempts with the dates for each attempt made.

7. List attempts to contact guardian:

Disclaimers (please check to confirm acceptance):