The 1915(c) C Behavioral Health Form is a structured document used to evaluate mental health needs for children and youth enrolled in Medicaid waiver programs. It gathers specific information across several clinical domains to support an informed care plan.
The form collects demographic data including the authorization number, names, dates of birth, and guardianship details. This information helps providers assign and monitor personalized outpatient or inpatient care for each individual.
A standard section documents the individual's behavioral health history, presenting problems, and relevant clinical background. Providers review prior treatment records and note substance use, current medical conditions, medication history, and known allergies.
The assessment covers mental status, risk factors, and cultural and language preferences. These details support coordination of care between providers and help identify the most appropriate service level.
The Plan of Care Services section links the individual to specific outpatient treatments and support services based on the clinical findings. This makes the 1915(c) form a comprehensive tool for person-centered behavioral health planning.
| Question | Answer |
|---|---|
| Form Name | C Behavioral Health Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | c m behavioral health, 1915 c independent behavioral health assessment, health behavioral c, c behavioral health |
| Form Authority | CMS (Centers for Medicare and Medicaid Services) |
| Assessment Type | Independent behavioral health assessment |
| Who Submits | Licensed behavioral health providers and case managers |