Follow the steps to complete the form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in an online editor.
2. In the first section, select whether this section is to be completed by the PSSYF provider by choosing either 'Authorization' or 'Discharge'. Specify the district office if applicable.
3. Fill in the PSSYF agency name and provide the provider ID number.
4. In the youth information section, input the identified youth's name and date of birth.
5. If applicable, enter the DCF family case number, which consists of up to six digits assigned by the DCF district office.
6. Complete the social security number field, which is assigned by the Social Security Administration.
7. If the youth is Medicaid eligible, provide the unique ID number or Medicaid number assigned by Medicaid.
8. In the authorization section, the PSSYF provider should indicate the reason for services and specify the start date of services.
9. If completing for discharge, state the reason for discharge by selecting an appropriate option (family refused services, family moved away, or other).
10. Fill in the name of the person completing the discharge and the discharge date.
11. Indicate whether the child/youth entered placement or successfully completed the program by selecting the corresponding option.
12. The DCF district must authorize PSSYF services by providing approval and obtaining the DCF district director's signature and printed name with the date.
13. Lastly, ensure that completed forms are emailed to the designated contacts: Debra.Cochran@vermont.gov and Amanda.Churchill@vermont.gov.
14. After filling out the form, save any changes made, and download, print, or share the completed document as needed.

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