Authorization Request Form Use this form to request authorizations and reauthorizations for Still Waters Individuals. Date MM slash DD slash YYYY REQUESTED FOR:Name - Requested FOR First Middle Last Suffix REQUESTED BY:Name - Requested by First Last Credentials Email - Requested byList your email here to receive a notification of this submission. CURRENT CLINICAL INFORMATIONANXIETY DISORDERSObsessions/Compulsions Mild Moderate Severe N/A Generalized Anxiety Mild Moderate Severe N/A Panic Attacks Mild Moderate Severe N/A Phobias Mild Moderate Severe N/A Somatic Complaints Mild Moderate Severe N/A PTSD Symptoms Mild Moderate Severe N/A MANIAInsomnia Mild Moderate Severe N/A Grandiosity Mild Moderate Severe N/A Pressured Speech Mild Moderate Severe N/A Poor Judgement / Impulsiveness Mild Moderate Severe N/A PSYCHOTIC DISORDERSDelusuons / Paranoia Mild Moderate Severe N/A Self-Care Issues Mild Moderate Severe N/A Hallucinations Mild Moderate Severe N/A Disorganized Thought Process Mild Moderate Severe N/A Loose Associations Mild Moderate Severe N/A DEPRESSIONImpaired Concentration Mild Moderate Severe N/A Impaired Memory Mild Moderate Severe N/A Psychometer Retardation Mild Moderate Severe N/A Sexual Issues Mild Moderate Severe N/A Appetite Disturbance Mild Moderate Severe N/A Irritability Mild Moderate Severe N/A Agitation Mild Moderate Severe N/A Sleep Disturbance Mild Moderate Severe N/A Hopelessness / Helplessness Mild Moderate Severe N/A SUBSTANCE ABUSELose of Control of Dosage Mild Moderate Severe N/A Amnesic Episode Mild Moderate Severe N/A Legal Problems Mild Moderate Severe N/A Alcohol Abuse Mild Moderate Severe N/A Opiate Abuse Mild Moderate Severe N/A Prescription Medication Abuse Mild Moderate Severe N/A Polysubstance Abuse Mild Moderate Severe N/A Other DrugsPlease list other drugs below. Mild Moderate Severe N/A List other drugs PERSONALITY DISORDEROddness / Eccentricities Mild Moderate Severe N/A Oppositional Mild Moderate Severe N/A Disregard for the Law Mild Moderate Severe N/A Recurring Self Injuries Mild Moderate Severe N/A Sense of Entitlement Mild Moderate Severe N/A Passive Aggresive Mild Moderate Severe N/A Dependency Mild Moderate Severe N/A Enduring Traits of: HISTORYTreatment History / Facility 1Admission Date 1 MM slash DD slash YYYY Discharge Date 1 MM slash DD slash YYYY Treatment History / Facility 2Admission Date 2 MM slash DD slash YYYY Discharge Date 2 MM slash DD slash YYYY Treatment History / Facility 3Admission Date 3 MM slash DD slash YYYY Discharge Date 3 MM slash DD slash YYYY ADDITIONAL INFORMATIONIn the text boxes provide details regarding current need for treatment and the behavior during the last 30 days that support the service requested.Risk of HarmCurrent / Hx of SI and HI that cause concern for safety, welfare and wellness of the memberFunctional StatusAbility to meet basic needs, fulfill usual role, and maintain health and wellnessCo-morbiditiesSymptoms and Tx for medical/SUD diagnosis in addition to primary HxEnvironmental StressorsStress in the environment such as home, school, and work that interfere with the member’s wellbeingNatural Support in the EnvironmentPersonal associations and relationships in the community that enhance the quality and security of the memberResponse to Current Treatment and Definition of Discharge Goals:Level of CareAcceptance and engagementTransportation AvailableMEDICATIONSMedication 1 Date Prescribed 1 MM slash DD slash YYYY Member Complaint w/ Medications 1 Yes No Medication 2 Date Prescribed 2 MM slash DD slash YYYY Member Complaint w/ Medications 2 Yes No Medication 3 Date Prescribed 3 MM slash DD slash YYYY Member Complaint w/ Medications 3 Yes No Medication 4 Date Prescribed 4 MM slash DD slash YYYY Member Complaint w/ Medications 4 Yes No Δ
