Name of Client

Section 1

Age: Is the person under age 18 or under age 21 who was receiving services prior to eighteenth birthday and that must be continued for therapeutic benefit.

Section 2

Diagnosis: * Individual with a clinically significant disorder of thought, mood, perception, orientation, memory or behavior that is listed in the current edition of the APA's Diagnostic an dStatistical Manual of Mental Disorders. * Excldues those children who are singularly diagnosed with intellectual disability.

Section 3

Limitations: Presents substantial limitation in a least 2 of the following 5 areas that have persisted for at least 1 year or are judged by a behavioral health professional to be at high risk of continuing for 1 year without professional intervention:

Section 4

MM slash DD slash YYYY