CDC Requests | Improving Lives Counseling Services

Client First Name*

(First 5 Letters) Client Last Name*

Client Insurance ID*

i.e. B12345678, YUQ123456, 003784297

Approximate Client Age*

Please enter a number from 1 to 105.

Action Requested ( Choose One )*

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.

Needs Therapist Assigned?*

Yes
No

Location*

City (If the city is Tulsa please provide nearest cross streets)*

First names and client ID numbers (four digit TH number) of all persons receiving services in this household*

Brief description of problem*

Reason for Needing an Extension or Information Update*

Reason for Discharge*

Name of person to contact (plus affiliation to client) and phone number to reach them at*

Requested Start Date*

Services Requested ( CDC-21 Only)*

Individual / Base Psychotherapy
Family Psychotherapy
Group Psychotherapy
Case Management

Pay Source/Insurance Provider*

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?*

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

Additional Information

Client Is Homeless
Should Be Eligible for Rehab
Need Letter of Termination
Need Letter of Collaboration

If you are requesting to discharge your client, you do NOT need to fill the form to have the client removed form you chart. We will do that automatically once we process the discharge. 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

Phone

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