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Children’s Therapeutic Services & Support (CTSS) Request Form

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Children’s Therapeutic Services & Support (CTSS) Request Form

Children’s Therapeutic Services & Support (CTSS) Request FormAdmin2022-12-21T20:13:51+00:00

If you have any questions, please call our client specialists at 651.313.8080 between the hours of 8:30 am and 5:00 pm CST Monday through Friday. We can help you find the appropriate services and schedule your first appointment.

Before we get started, please have your insurance information and medical history.

ARMHS (Adult Rehabilitative Mental Health Services) is a high intensity mental health outpatient service that often includes multiple hours of services per week for clients 18 and older. In order to qualify for ARMHS, individuals must have mental health concerns that negatively impact daily life. The focus is different for each individual, but the intent is always to improve basic living and social skills at home and in the community. ARMHS providers are focused on supporting and empowering clients to do for themselves and will address underlying mental health barriers to daily functioning. The ARMHS provider’s role is to identify functioning that’s impacted by mental health concerns and to foster growth and rehabilitation in these areas. They will support clients in practicing skills from a mental health perspective.

ARMHS is not Case Management, ILS, PCA, Medication Management, transportation, etc.

To make a referral, please complete the following form. A member of the KESMA Flame Lily team will reach out if there are questions. Please trust that if you receive the notification your referral was received that we are tracking it and will reach out to the client or the legal guardian when we are ready to schedule services.

Children’s Therapeutic Services and Supports (CTSS) is a flexible package of rehabilitative and therapeutic mental health services designed to meet the unique needs of the individual child. Each child and their guardian/family works with a skills provider and a therapy provider in a collaborative care team. CTSS provides varying degrees of care for children and youth who require more than psychotherapy alone to return lost capabilities, gain new skills, and progress along a path toward their peak development. Clients and families participating in CTSS services can expect two appointments per week: one with their therapist and one with their skills provider. Because CTSS with KESMA Flame Lily includes BOTH Therapy and Skills you do NOT need to make a separate referral for Therapy. If you are ONLY interested in Therapy, please complete the In-Home Therapy referral form. KESMA Flame Lily does not provide Skills Work for minors separate from therapy services. To make a referral, please complete the following form. A member of the KESMA Flame Lily team will reach out if there are questions. Please trust that if you receive the notification your referral was received that we are tracking it and will reach out to parent/guardian when we are ready to schedule services.

Client Name

Sex

Client Phone Number *

Phone Number *

Address *

Street Address Line 2 *

City *

State / Province *

ZIP / Postal Code *

Country

Minnesota County of Service (If the client's county of residence is not listed, we do not offer this service in their county) *

Client date of Birth

Age: *

Referral Date

Legal Guardian

If Yes, Guardian Name: *

Guardian Phone Number *

Phone Number *

Relationship To Child *

Email (referring party) *

Phone Number (Referring Party) *

Phone

Insurance Company *

* Eligibility for this State-funded programming requires an active form of Minnesota Medical Assistance. This can be Straight MA or a PMAP plan through an insurance carrier. Before KESMA Flame Lily can begin providing services to any client, we MUST have correct insurance information and an active insurance plan. This includes the PMAP insurance provider if there is one, member ID, group number, and the MA# or PMI#. Straight MA will only need their 8-digit MA number.

Group Number *

ID Number *

PMI# *

Social Worker

Diagnosis *

Language Preference *

Interpreter Needed?YesNo

Therapist gender preference *

Availability *

What kind of struggles is this child having? Why are CTSS services being considered?

How might skills work help this child? Skills work includes practicing coping skills, structure, communication, emotion regulation, and more!

What other services is this child currently receiving (psychiatry, therapy, day treatment, case management, etc.)? Please Note: Clients must commit to both a therapist and skills worker through KESMA Flame Lily in order to engage in CTSS services.

Briefly note any family concerns:

Does the client/family have pets? If so, what kind?

Is the client open to telehealth services during the pandemic?YesNo, in person services only

Any additional information to help find a good match for an CTSS practitioner, please write below

How did you hear about us?

Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)Other

As soon as we receive a referral, KESMA Flame Lily Staff will review it and check for complete information and insurance eligibility. Incomplete information will add time to processing. Referrals with inactive insurance will be passed back to the Referring Party and they are invited to re-refer once MA Plan is active. In cases where MA is applied for but not yet approved, documentation of application will be required to consider scheduling.

First Name *

Last Name *

Preferred Name

Pronouns

Sex

Phone Number *

Mobile Phone Number

Email *

Street Address *

Street Address Line 2 *

City *

State/Province *

ZIP / Postal Code *

Country

Date *

Please upload a photo of the front and back of your driver's license or ID. *

No file chosen

Is this person under the age of 18? *

Are the parents/guardians of this person divorced or separated? *YesNo

Parent/Guardian 1 Name *

Parent/Guardian 1 Email *

Parent/Guardian 1 Phone *

Parent/Guardian 2 Name *

Parent/Guardian 2 Email *

Parent/Guardian 2 Phone *

This is for maternal mental healthThere are currently divorce or custody issues/concerns

What days/times work best? *

Preferred Office Location *

If an immediate opening is available via telehealth at a location other than your preferred location, are you open to considering this option under the assumption you would continue seeing your provider virtually?YesNo

Insurance Company *

Before KESMA Flame Lily can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #

Group Number *

ID Number *

Who is the policy holder for your insurance plan?SelfRelative

Please upload photos of the front and back of your insurance card.

No file chosen

Do you have a supplemental insurance plan?

Therapist Gender Preference *

Previous/Current Diagnosis (if applicable)

Are you a current or past KESMA Flame Lily client?

How do you prefer we contact you? *

PhoneEmailOther

Would you also like to schedule a Medication Management appointment at this time? *YesNo

Please provide a brief summary describing your goals in therapy or the type of support you are seeking: *

How many Intake Assessments have you had in the current calendar year? *

Our new program, KESMA Flame Lily, is an 8 week program for clients 18 + who have previously been in control of their mental health but are having trouble managing their stress recently. Over the course of 8 weeks, clients learn skills to help them cope with everyday stress and anxiety. You can learn more about KESMA Flame Lily by visiting www.flamelilytherapies.com. Are you interested in exploring whether KESMA Flame Lily is the right fit for you?YesNo

Any additional information to help find a good match for a practitioner please write below:

As soon as we receive a referral, KESMA Flame Lily staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.