Client Simple Treatment Plan Request | Improving Lives Counseling Services

Now Hiring State-Wide Make A Referral Areas We Serve Frequent Questions Make A Payment

To Add Goals and Objectives to Client’s Simple Treatment Plans

Is this for a VA Client?(Required)

VA coverage

other pay source

VA Group Number provided by Leria(Required)

This number will be listed in the NCF email and starts with "VA"

VA Client STP Request(Required)

Initial Request

Extension

Client Name(Required)

First First 5 Letters of Last Name

Insurance ID Number(Required)

or Phone Number if Self Pay

Pay Source(Required)

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Pay Source

Requested Start Date(Required)

Diagnosis(Required)

Problem Statement 1(Required)

Goal Statement 1(Required)

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Objectives for Problem/Goal 1

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

Objectives for Problem/Goal 1(Required)

Objective

Type of Service (Base Psychotherapy, Family, Group)

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

Problem Statement 2(Required)

Goal Statement 2(Required)

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Objectives for Problem/Goal 2

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

Objectives for Problem/Goal 2(Required)

Objective

Type of Service (Base Psychotherapy, Family, Group)

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

Do you need to add more problems and goals?(Required)

Yes

Problem Statement 3

Goal Statement 3

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Objectives for Problem/Goal 3

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

Objectives for Problem/Goal 3

Objective

Type of Service (Base Psychotherapy, Family, Group)

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

Problem Statement 4

Goal Statement 4

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Objectives for Problem/Goal 4

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

Objectives for Problem/Goal 4

Objective

Type of Service (Base Psychotherapy, Family, Group)

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

Modalities Being Used in Sessions(Required)

Progress Since Last Authorization(Required)

Estimated no. of sessions per month(Required)

Indicate how many services per month per service type

Estimated Date of Discharge(Required)

Discharge Plan Criteria (client-specific behaviors)(Required)

similar to what you would enter on a medicaid treatment plan addendum page

Upload Documents

Drop files here or

Max. file size: 50 MB.

Clinician Name(Required)

Clinician Email(Required)

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Requested Start Date