CDC Requests Client First Name*Client Last Name Initial*Client ID #*Approximate Client Age*Action Requested ( Choose One )*CDC 21 - Preadmission AuthorizationAssessment ReviewCDC 23 - Initial Treatment Plan AuthorizationCDC 42 - 6 Month Update AuthorizationDischarge ( Indicate Reason Below )Simple Treatment PlanNeeds Therapist Assigned?*YesNoLocation*Tulsa Main OfficeTulsa 41st Street OfficeTulsa Garnette OfficeSouth Tulsa Community HouseBroken ArrowTahlequahPryorOwasso 86th Street North OfficeOwasso 106th Street North OfficeSapulpaCowetaNormanStillwaterHome / OtherCity (If the city is Tulsa please provide nearest cross streets)*Brief description of problem*First names and client ID numbers (four digit TH number) of all persons receiving services in this household*Reason for Discharge*Diagnosis*Name of person to contact (plus affiliation to client) and phone number to reach them at*Requested Start Date* Date Format: MM slash DD slash YYYY Services Requested ( CDC-21 Only )* Individual / Base Psychotherapy Family Psychotherapy Case Management Services Requested ( Simple Treatment Plan Only )* Individual / Base Psychotherapy Family Psychotherapy Group Psychotherapy Have you verified with the insurance provider for coverage of family sessions?*YesNoDoes the client have a secondary insurance?*YesNoName of secondary insurance*Therapist (If none enter N/A)*Therapist (If none enter N/A)*Case Manager ( If none enter "N/A" )*Additional Information Client Is Homeless Should Be Eligible for Rehab Should Be Eligible for Case Management Supporting Documentation Has Been Turned In Need Letter of Termination Need Letter of Collaboration Requestor's Email Address ( To be emailed a copy of the submission )* EmailThis field is for validation purposes and should be left unchanged.
