PA Adjustment Request | Improving Lives Counseling Services

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To Add Goals and Objectives to Treatment Plans that are IN USE

Client Name(Required)

First First 5 Letters of Last Name

Insurance ID Number(Required)

Select Needed Adjustments(Required)

Need Date Changed

Need New Goals and/or Objectives

Need Rehab Added

Need CM Added

Need Testing Added

Need Anger Group Objectives

Need Parenting Group Objectives

Need Other Group Objectives

Need Units Moved

Describe how you want units moved (i.e. change family to 4 and individual to 36)(Required)

Total units must remain the same. We cannot add more units if it will make the PA go over allowed amount.

Date Needed(Required)

Note: For CDC 23s and CDC42s, the date can only be backdated 7 days from the CURRENT day.

Additional Group Members

Client Name

First Name

First 5 Letters of Last Name

TH ID Number

Click on the + button to add more lines

Problem Statement 1(Required)

This can be an existing problem statement but you must tell us which one you want it added to if you are using an existing problem statement. For example you can type "use problem/goal 1" etc.

Goal Statement 1(Required)

This can be an existing goal statement but you must tell us which one you want it added to if you are using an existing goal statement. For example you can type "use problem/goal 1" etc.

Objectives for Problem/Goal 1(Required)

Specific Objective

Type of Service (individual, family, rehab, etc.)

at least 2 objectives are required per problem/goal. Click on the + to add more objectives

Problem Statement 2

Goal Statement 2

Objectives for Problem/Goal 2

Specific Objective

Type of Service (individual, family, rehab, etc.)

at least 2 objectives are required per problem/goal. Click on the + to add more objectives

Problem Statement 3

Goal Statement 3

Objectives for Problem/Goal 3

Specific Objective

Type of Service (individual, family, rehab, etc.)

at least 2 objectives are required per problem/goal. Click on the + to add more objectives

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SSI, Discharge or IEP Letter for Rehab

Max. file size: 50 MB.

If your client is not showing eligible for rehab in TH please submit supporting documents here

SSI, Discharge or IEP Letter for Rehab(Required)

Drop files here or

Max. file size: 50 MB.

If your client is not showing eligible for rehab in TH please submit supporting documents here

Clinician Name(Required)

Clinician Email(Required)