Enhanced Continued Stay Confirmation

90-Day Confirmation for Specialized T3C Service Packages

90-Day Cycle

Service Plan Integration

This form is incorporated into the Service Plan for children receiving specialized T3C service packages requiring continued stay confirmation, including Mental & Behavioral Health, IDD/Autism Spectrum Disorder, Substance Use, and Treatment Foster Family Care Support Services.

Review frequency: 90 days (MH, IDD, SU) per TAC §749.1335 and T3C Blueprint requirements.

Section Progress20% Complete

Header Information

Basic child and case information

Child's Name *

Child's Date of Birth *

Case Number *

Current Service Package *

Placement Start Date *

Review Date *

DFPS/SSCC Caseworker Name *

DFPS/SSCC Caseworker Email *

Service Plan Review Period - From *

Service Plan Review Period - To *

Previous Enhanced Review Date

Next 90-Day Review Due *

1st 90-Day Review

Placement Date: 1/15/2024

Days in Placement: 696

Review #:

CANS 3.0 Assessment Data

Most recent assessment information

Most Recent CANS 3.0 Assessment Date *

Current CANS Score *

Previous CANS Score

Trend Indicator *

Clinical Justification

Required elements per T3C Blueprint

Child continues to meet admission criteria for the service package *

Child is benefitting from the Evidence-informed Treatment Model *

Less-restrictive T3C Basic Foster Home Service Package is NOT appropriate *

Clinical Justification Narrative *

Treatment Progress and Engagement Metrics *

Barriers to Step-Down to Basic Services *

Package-Specific Assessment

Mental & Behavioral Health specific elements

Psychiatric Stability Indicators

Crisis Frequency/Severity

Medication Compliance

Therapeutic Progress

Family Readiness for Managing Mental Health Needs

Service Plan Integration

Connection to broader service planning process

This Enhanced Continued Stay Confirmation is attached to and incorporated into the Service Plan dated:

Service Plan Date

Service Plan Document ID/Number

Note: This confirmation must be completed concurrently with each 90-day Service Plan Review.

Certification

Required signatures and certifications

Program Director Signature *

Treatment Director Signature *

Certification Statement: We certify that Emma Johnson continues to meet criteria for and is benefitting from the Mental & Behavioral Health Support Services, and that the less-restrictive T3C Basic Foster Home Service Package is not appropriate to meet the child's needs at this time.

Distribution Requirements

Required notifications and record keeping

Copy will be sent to SSCC/DFPS within 15 business days

Date Sent to SSCC/DFPS

Copy attached to Service Plan in Radius

Compliance Statement: This form fulfills T3C Blueprint requirements for 90-day written confirmation of continued stay necessity as outlined in the Mental & Behavioral Health Support Services (p.85) specifications. This form is conditionally incorporated into the Service Plan when specialized packages are utilized. Policy Reference: FC-MH-01