Name
DOB
Social Security #:
Sex:
Race
Primary Language:
Address
City
State
Zip Code
Guardian Name
Relationship
Phone Number
Email
Client’s School
Grade
IEP
Primary Insurance
Member ID
Concerns/Problems/Reason for Referral
INTERESTED IN (check all that apply):
Name
Referral Number
Referral Email
Date
6900 Houston Rd, Ste 26, Florence, KY 41042.
Determination Criteria Checklist for Severe Emotional Disability (SED)
Relates to KRS 200.503(3) and 907 KAR 15:060, 15:065, 15:050 and 15:055, and 908 KAR 2:260. Per KRS 200:501 – Children with an SED who are receiving institutional care or are at risk of institutional placement shall be given priority for services pursuant to KRS 200:501–200.509.
The following table illustrates the criteria that shall be met for an individual to be designated as SED. To make an SED designation, Sections 1, 2 and 4 are required and at least two of five in Section 3.
Section 1: Age
Individual is under age 18 or under age 21 and was receiving services prior to eighteenth birthday that must be continued for therapeutic benefit.
Section 2: Diagnosis
Individual has a clinically significant disorder of thought, mood, perception, orientation, memory or behavior that is listed in the current edition of the American Psychology Association’s Diagnostic and Statistical Manual of Mental Disorders. This excludes those children who are singularly diagnosed an intellectual disability
Section 3: Limitations
Individual presents substantial limitations in at least two of the following five areas that have persisted
for at least one year or are judged by a behavioral health professional to be at high risk of continuing
for one year without professional intervention:
a) Functioning in self-care: Impairment in self-care is manifested by a person’s consistent inability to
provide, sustain and protect his or herself at a level appropriate to his or her age (e.g., significant
basic hygiene or self-care needs, pattern of self-injurious behavior, pattern of physically reckless
decision-making, eating disorders, failure to address serious health, nutrition, safety or medical
needs, threatens or attempts suicide).
b) Functioning in interpersonal relationships: Impairment of interpersonal relationships (including
community relationships) is manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults. Children and adolescents exhibit constrictions in
their capacities for shared attention, engagement, initiation of two-way effective communication
and shared social problem solving; inability to maintain safety without assistance; a consistent lack
of age-appropriate behavioral controls, decision-making, judgment and value systems that result in
potential out-of-home placement (e.g., repeated or serious aggressive interactions with peers or
adults in the community, isolated or withdrawn much of the time, behavior which consistently alienates peers).
c) Functioning in family life: Impairment in family function is manifested by the inability to live in a family or family-type environment. This can include a pattern of emotional or disruptive behavior exemplified by repeated and/or unprovoked aggravating or violent behaviors aimed at others in the home (siblings, parents and/or other caretakers such as relative caregivers, foster parents) and seriously disrupts the home; disregard for safety and welfare of self or others in the home (e.g., fire setting, serious and chronic destructiveness, self-injurious behavior, inability to conform to reasonable expectations that may result in removal from the family or its equivalent). Child-caregiver and family characteristics do not include developmentally based adaptive patterns that support social-emotional well-being. d) Functioning at school/work: Impairment in school/work function is manifested by an inability to pursue educational goals in a normal time frame (e.g., consistently failing grades, repeated truancy, expulsion, property damage or violence toward others); the inability to learn social and intellectual skills from teachers in available educational settings (e.g., failing
most courses or some courses, if performance is significantly below ability, dropped out of school without alternative academic or vocational involvement or has serious attendance problems, behavior problems result in frequent intervention or suspensions, special class placement or expulsion); or inability to be consistently
employed at a self-sustaining level (e.g., inability to conform to work schedule, poor relationships with supervisor and other workers, hostile behavior on the job). e) Functioning in self-direction: Impairment in self-direction is manifested by an inability to control behavior and make decisions in a manner appropriate to his or her age (e.g., repeated or serious violations of the law or community norms; lacks confidence or competence to perform routine age-appropriate functions in the community such as running an errand; behavior is repeatedly disruptive or inappropriate in community settings; requires adult supervision in community well after age when should have more autonomy). NOTE: For early childhood functioning, major impairments undermine the fundamental foundation of
healthy functioning exhibited by:
• Rarely or minimally seeking comfort in distress
• Limited positive affect and excessive levels of irritability, sadness or fear • Disruptions in feeding and sleeping patterns
• Failure, even in unfamiliar settings, to check back with adult caregivers after venturing away
• Willingness to go off with an unfamiliar adult with minimal or no hesitation • Regression of previously learned skills
• Inability to make and keep friends
• Inability to share
Section 4: Duration
Presents substantial limitations or symptomology in the areas above that have persisted for at least one year or are judged by a mental health professional to be at high risk of continuing for one year without professional intervention
Section 4: Interstate compact
Interstate compact (per KRS Chapter 615)
Individual is a Kentucky resident and is receiving residential treatment for emotional disability through the interstate compact.
Section 4: Department
Department for Community Based Services (DCBS) out of home placement The DCBS has removed the child from the child’s home and has been unable to maintain the child in a stable setting due to emotional disturbance.
This individual meets the criteria for the designation of Severe Emotional Disability (SED). Documentation of the existence of these criteria of age, diagnosis, disability and duration is present in the individual’s medical record and assessment has been conducted by a qualified, licensed behavioral health professional..
Eligibility Criteria for Autism Services (Per KY Medicaid Behavioral Health Guidelines) To Qualify for Autism Services, the individual must meet the following criteria: Diagnosis of Autism Spectrum Disorder (ASD): Must be diagnosed by a qualified medical professional using standardized diagnostic tools (ADOS-2, CARS-2, M-CHAT).Age Requirement: Services are available for individuals under the age of 21.Functional Limitations: The individual must exhibit significant impairment in at least wo of the following domains:Medical Necessity: Services must be deemed medically necessary based on a comprehensive evaluation.Insurance Eligibility: The individual must be eligible for Medicaid or another approved insurance plan that covers autism services.
Supporting Documentation Required for Referral:
