Follow the steps to fill out the form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editing tool.
2. Begin by entering the applicant information, including the date of the intake appointment, referral source, applicant ID or Social Security Number, date of birth, gender, and the applicant's full name (last, first, middle). Make sure to include the mailing address, city, county, zip code, and telephone number.
3. Proceed to the provider agency information section. Here, fill out the provider's name, email address, city, address, ZIP code, telephone number, state, and fax number.
4. Next, enter the clinical information. Include the current DSM-5 or ICD-10 diagnoses, both the code and the narrative, especially noting any substance use disorders. Specify the primary diagnosis and list any other conditions requiring treatment, including medical conditions.
5. List the signs and symptoms that substantiate the qualifying primary diagnosis. Provide details about the medication currently being taken, including dosage and frequency, and the prescriber’s information.
6. If there are no current medications, state whether a medical professional has determined that medication is necessary for symptom control by answering 'yes' or 'no' and providing the medical professional's name and title.
7. Complete the history of mental health treatment section. Indicate if the individual has a history of adult outpatient mental health treatment and list any services they have participated in.
8. Indicate the history of inpatient adult mental health treatment. Provide the number of acute psychiatric admissions and the date of the most recent admission, along with the reasons for admission and any commitments to the Montana State Hospital.
9. Answer the questions regarding the individual’s ability to work, live independently, care for themselves, and their housing situation related to mental illness. Provide brief descriptions where applicable.
10. Identify current risk factors such as suicidal ideation or danger to others. Describe the proposed treatment plan, specifically identifying services such as medications and case management.
11. Finally, the provider must certify the assessment by signing and dating the form. Ensure that all provided information is true and correct.
12. After filling out the form, save your changes, and proceed to download, print, or securely share the completed document as instructed in the submission section.

Complete the MT DPHHS Clinical Eligibility Form For MHSP And WASP online to access vital mental health services.