CDC Requests | Improving Lives Counseling Services

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This field is for validation purposes and should be left unchanged.

Client First Name*

(First 5 Letters) Client Last Name*

Client Insurance ID*

i.e. B12345678, YUQ123456, 003784297

Action Requested ( Choose One )*

Requested Start Date*

Services Requested*

Individual Psychotherapy
Family Psychotherapy
Group Psychotherapy
Case Management

Confirmation*

I have turned in the updated treatment plan signature page and 6 month survey

Treatment plan signature pages (medicaid only) and 6 month surveys are required for ALL 6 month updates (including STP requests for insurance and private pay clients) - If this is an initial STP request please just check the box. No survey or signature page is needed.

Client Current Phone Number*

Ensure this is updated in TH also

Client Current Address*

Street Address Address Line 2 City State ZIP Code

Ensure this is updated in TH also

Client Current Email Address*

Ensure this is updated in TH also

If you enter the word "unknown" or "n/a" as part of the email address, this form will not process correctly and we will never receive a copy of it.

Info Updated*

I have updated this information in TH

I verify that I have updated ThinkHealth with any new demographic information for this client. If nothing has changed, I verify that all information currently listed in ThinkHealth is correct and accurate.

Reason for Needing an Extension or Information Update*

Reason for Discharge*

Does the client have a secondary insurance?*

Yes
No

Name of secondary insurance*

Therapist*

If unsure enter UNKOWN, if the therapist needs to be assigned enter ASSIGN

Case Manager*

If unsure enter UNKOWN, if none enter N/A

To remove the client from your list, go to the PATIENT MODULE, select the NOTES AND ASSIGNMENTS tab, and uncheck the box next to your name. Thank you.

Requestor's Email Address ( To be emailed a copy of the submission )*

Upload page 1 of intake or treatment plan signature page

Max. file size: 10 MB.

Not Needed if Paperwork was Completed Electronically. Remember: ALL ORIGINAL DOCUMENTS STILL NEED TO BE SUBMITTED TO MAIN TULSA OFFICE