[ FORM 7 —Use the top of this page for your letterhead.] Checklist for Assessing the Medical Necessity for Psychotherapy Patient: Identification number: Based upon my ongoing assessment, the above-named patient requires continued psychotherapy and or psycho-therapeutic case management for the following reasons: q This patient has a history of regression to a lower level of functioning without ongoing psychotherapy services. q This patient has improved considerably in the past, but his or her functioning and condition deteriorated follow-ing a reduction of frequency in therapy visits. q This patient has a history of noncompliance with other essential components of his or her care (medications, day treatment, attendance, sobriety, etc.), and psychotherapy helps this patient to improve his or her level of adherence to planned treatment. q This patient’s current level of functioning is such that psychotherapy and/or case management services are needed to support maintenance at this (lower) level of functioning. q
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Psychiatric treatments, school functioning, Individual Psychotherapy, Psychotherapeutic treatment