Please complete all parts as clearly and as specifically as possible. Omissions, generalities and illegibility will result in the form being returned for completion or clarification and not be considered a complete request.
*Please do not use this form for RTC Substance Use requests. Use the Facility Based Treatment Form for RTC Substance Use requests.
Facility is primarily providing a continuous structured therapeutic program specifically designed to treat behavioral health disorders and is not a group or boarding home, boarding or therapeutic school, half-way house, sober living residence, wilderness camp or any other facility that provides Custodial Care.***
What attempts have been made to treat the patient with the maximum intensity of services available at a less intensive level of care, especially within the past six months?
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