WAC 296-31-060
What reports are required from mental
health providers? The crime victims compensation program
requires the following reports from mental health providers:
(1) Initial response and assessment: Form I: This
report is required if you are seeing the client for six
sessions or less, and must contain:
(a) The client's initial description of the criminal act
for which they have filed a crime victims compensation claim;
(b) The client's presenting symptoms/issues by your
observations and the client's report;
(c) An estimate of time loss from work as a result of the
crime injury, if any. Provide an estimate of when the
individual will return to work, why they are unable to work,
the extent of impairment and the prognosis for future
occupational functioning; and
(d) What type of intervention(s) you provided.
EXCEPTION:
If you will be providing more than six sessions it is not necessary to complete Form I, instead complete Form II.
(2) Initial response and assessment: Form II: This
report is required if more than six sessions are anticipated. Form II must be submitted no later than the sixth session, and
must contain:
(a) The client's initial description of the criminal act
for which they have filed a crime victims compensation claim;
(b) A summary of the essential features of the client's
symptoms related to the criminal act, beliefs/attributions,
vulnerabilities, defenses and/or resources that lead to your
clinical impression (refer to current DSM and crime victims
compensation program guidelines);
(c) Any preexisting or coexisting emotional/behavioral or
health conditions relevant to the crime impact if present, and
how they may have been exacerbated by the crime victimization;
(d) Specific diagnoses with current DSM or ICD code(s),
including axes 1 through 5, and the highest GAF in the past
year;
(e) Treatment plan based on diagnoses and related
symptoms, to include:
(i) Specific treatment goals you and the client have set;
(ii) Treatment strategies to achieve the goals;
(iii) How you will measure progress toward the goals; and
(iv) Any auxiliary care that will be incorporated.
(f) A description of your assessment of the client's
treatment prognosis, as well as any extenuating circumstances
and/or barriers that might affect treatment progress; and
(g) An estimate of time loss from work as a result of the
crime injury, if any. Provide an estimate of when the
individual will return to work, why they are unable to work,
the extent of impairment and the prognosis for future
occupational functioning.
(3) Progress note: Form III: This report must be
completed after session fifteen has been conducted, and must
contain:
(a) Whether there has been substantial progress towards
recovery for the crime related condition(s);
(b) If you expect treatment will be completed within
thirty visits (for adults) or forty visits (for children); and
(c) What complicating or confounding issues are hindering
recovery.
(4) Treatment report: Form IV: This report must be
completed for authorization for treatment beyond thirty
sessions for adults or forty sessions for children, and must
contain:
(a) The diagnoses at treatment onset with current DSM or
ICD code(s), including axes 1 through 5, and the highest GAF
in the past year;
(b) The current diagnoses, if different now, with current
DSM or ICD code(s), including axes 1 through 5, and the
highest GAF in the past year; and
(c) Proposed plan for treatment and number of sessions
requested, and an explanation of:
(i) Substantial progress toward treatment goals;
(ii) Partial progress toward treatment goals; or
(iii) Little or no progress toward treatment goals.
(5) Treatment report: Form V: This report must be
completed for authorization for treatment beyond fifty
sessions for adults or sixty sessions for children, and must
contain:
(a) The diagnoses at treatment onset with current DSM or
ICD code(s), including axes 1 through 5, and the highest GAF
in the past year;
(b) The current diagnoses, if different now, with current
DSM or ICD code(s), including axes 1 through 5, and the
highest GAF in the past year;
(c) Proposed plan for treatment and number of sessions
requested, and an explanation of:
(i) Substantial progress toward treatment goals;
(ii) Partial progress toward treatment goals; or
(iii) Little or no progress toward treatment goals.
(6) Termination report: Form VI: If you discontinue
treatment of a client for any reason, a termination report
should be completed within sixty days of the client's last
visit, and must contain:
(a) Date of last session;
(b) Diagnosis at the time client stopped treatment;
(c) Reason for termination (e.g., goals achieved, client
terminated treatment, client relocated, referred to other
services, etc.); and
(d) At this point in time do you believe there is any
permanent loss in functioning as a result of the crime injury?
If yes, describe symptoms based on diagnostic criteria for a
DSM diagnosis.
(7) Reopening application: This application is required
to reopen a claim that has been closed more than ninety days,
to demonstrate a worsening of the client's condition and a
need for treatment. We will reimburse you for filing the
application, for an office visit, and diagnostic studies
needed to complete the application. No other benefits will be
paid until a decision is made on the reopening. If the claim
is reopened, we will pay benefits for a maximum of sixty days
prior to the date we received the reopening application.