CDC Requests Client First Name*Client Last Name Initial*Client ID #*Approximate Client Age*Please enter a value between 1 and 105.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 (Please indicate a specific office or area)*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*Requested Start Date* 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?*YesNoTherapist (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.
