Letter of Collaboration | Improving Lives Counseling Services

This form is ONLY for clients that you are still seeing that have a Prior Authorization (PA) open at another agency. If you are needing to discharge, transfer or remove a client from your list please use the appropriate forms for those requests. This form only applies to MEDICAID clients.

Client Information

First Name of Client(Required)

First 5 Letters of Last Name(Required)

TH ID(Required)

Medicaid ID(Required)

Do You Need an LOT or an LOC?

Letter of Termination (LOT)

Letter of Collaboration (LOC)

ILCS Services Information

Service WE Will be Providing at ILCS(Required)

Individual Psychotherapy

Family Psychotherapy

Group Psychotherapy

Individual Rehab

Group Rehab

Case Management

Only one agency is allowed to provide each type of service i.e. They cannot get individual psychotherapy at two different agencies

How many hours of individual psychotherapy per week(Required)

How many hours of family psychotherapy per week(Required)

How many hours of group psychotherapy per week(Required)

How many hours of individual rehab per week(Required)

How many hours of group rehab per week(Required)

How many hours of case management per month(Required)

Other Agency Information

Name of Other Agency

Contact Information for Other Agency

Services Being Provided at Other Agency

Individual Psychotherapy

Family Psychotherapy

Group Psychotherapy

Individual Rehab

Group Rehab

Case Management

Medication Management

Please ask the client for this information

Clinician Contact Information

Your Name(Required)

Email(Required)

Request for Collaboration or Termination

Client Information

ILCS Services Information

Other Agency Information

Clinician Contact Information