Client Simple Treatment Plan Request 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 PayPay Source(Required)Select OneAetnaAlliance CoalAllied NationalBlueCross Blue ShieldChampVACigna EAP ServicesCigna Health and Life Insurance Co.Edison Health SolutionsGPAGroup Benefit Services (GBS)Health SmartHealthcare HighwaysHealthCare Solutions GroupHealthChoiceHealthScopeHealthSmartHealthSmart Benefit SolutionsHumanaChoice PPOHumana MilitaryMedicaMedicare - Aetna CoventryMedicare - HumanaMedicare - Other Supplemental PlanMedicare - OriginalMeritain HealthThe Kempton GroupTricare EastUMR - Wausau/UHISUnited Health Care/United Behavioral HealthUHC MedicareWebTPAOtherThis field is hidden when viewing the formPay SourceRequested Start Date(Required) MM slash DD slash YYYY Diagnosis(Required)Problem Statement 1(Required)Goal Statement 1(Required)This field is hidden when viewing the formObjectives for Problem/Goal 1 Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesObjectives for Problem/Goal 1(Required)ObjectiveType of Service (Base Psychotherapy, Family, Group) Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesProblem Statement 2(Required)Goal Statement 2(Required)This field is hidden when viewing the formObjectives for Problem/Goal 2 Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesObjectives for Problem/Goal 2(Required)ObjectiveType of Service (Base Psychotherapy, Family, Group) Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesDo you need to add more problems and goals?(Required) Yes No Problem Statement 3Goal Statement 3This field is hidden when viewing the formObjectives for Problem/Goal 3 Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesObjectives for Problem/Goal 3ObjectiveType of Service (Base Psychotherapy, Family, Group) Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesProblem Statement 4Goal Statement 4This field is hidden when viewing the formObjectives for Problem/Goal 4 Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesObjectives for Problem/Goal 4ObjectiveType of Service (Base Psychotherapy, Family, Group) Add Removeat least 2 objectives are required per problem/goal. Click on the + to add more objectivesModalities 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 typeEstimated Date of Discharge(Required)Discharge Plan Criteria (client-specific behaviors)(Required)similar to what you would enter on a medicaid treatment plan addendum pageUpload Documents Drop files here or Select files Max. file size: 50 MB. Clinician Name(Required)Clinician Email(Required) This field is hidden when viewing the formRequested Start Date Δ