Community Support
Network

SMI Provider Forms & Checklist

Please check that the following documents are included in the submission: 

Consent for Assessment

This must be signed and dated within one business day of submission of application to Solari. The assessment cannot be processed without this form signed and dated appropriately. 

*Note for COT applicants: Court documents & approved treatment plan are required if the applicant does not consent.

Download English Form

Download Spanish Form

Seriously Mentally Ill (SMI) Determination Form

Part C Additional Addenda (this form must be signed by a licensed clinician), the assessment cannot be processed without this form signed and dated appropriately.

Download Form

Core Assessment

This must be dated within six months of the submission and cannot be a “part E”.

Download Form

Waiver of Three Day Determination Form

Please note that applicants are encouraged to waive their right to a three-day determination. Generally speaking, evidence suggests that additional time to review and pursue historical treatment records result in a positive outcome.

If this form is not submitted, the determination will be made in three days.

Download English Form

Download Spanish Form

Demographic Form

It is helpful to have the most current address, phone number and other pertinent demographic information in order to most effectively communicate with the client and other involved parties through the determination process.

Download Form

Releases of Information

It is helpful to have an ROI for the emergency contact or family members that the client would like us to be able to communicate with regarding their care/determination as well as any prior outpatient and inpatient providers if the client would like these records considered as part of the determination.

Download English Form

Download Spanish Form

Any additional records that may support SMI Criteria

Evaluators should make applicants aware that asking for additional time may improve the likelihood of being determined eligible for SMI services.

If determined to be eligible for SMI services, the T/RBHA will assign the applicant to an SMI clinic. Applicants can choose which clinic they would like to attend.

 

Decertification Form

Download Attestation Form

 

Considerations 

Solari is committed to making well-informed, accurate, and timely SMI Determinations, maintaining fidelity of SMI criteria, and collaborating with providers to make this process as transparent as possible. 

SMI Evaluation Referrals

The points below are designed to assist you in making appropriate referrals for an SMI evaluation and to provide guidance on what information is especially relevant when an evaluation is being reviewed for determination.

Please consider the information below when deciding whether to refer someone for an SMI evaluation:

  • Does the individual have a current SMI qualifying diagnosis on record AND does the record support the diagnosis by clear description of corresponding symptoms (symptom type, onset, duration, and frequency), behaviors consistent with the diagnosis, and clinical observations consistent with the diagnosis? 
  • Does the individual have, documented in the hospital record, severe functional impairment that is directly linked to the SMI qualifying diagnosis AND has that functional impairment been occurring for at least the past 12 months or 6 months with an expected continued duration of another 6 months? 
  • In addition to the above, is it clear that the symptoms and functional impairment are not primarily due to substance use/dependence, medical conditions (i.e. chronic pain, brain injury, seizure disorder, thyroid condition, obesity, diabetes, etc.), developmental disability, antisocial personality traits or disorder, situational stressors, or other diagnoses or factors? If any of those factors are present, is there documentation to show that they have been ruled out as the primary reason for their impairment? 
  • For those admitted with recent or current substance use: 
    • Is there is evidence of periods of sustained sobriety with persistence of symptoms and functional impairment during those periods? 
    • Is there evidence that symptom onset was prior to onset of substance use? 
  • Is there a history of mental illness in the family; have family members been treated for mental illness and/or attempted/died by suicide? 

For inpatient individuals: 

  • Does the individual have a history of outpatient mental health treatment that has been unsuccessful in managing the symptoms of a qualifying diagnosis? (If not, are they eligible for GMH/SA or other OP services and has that been considered?) 
  • Does the individual have a history of chronic SI, suicide attempts, and/or psychiatric hospitalizations (not all while using substances)? 
  • Has the psychiatric provider seen the individual and do they agree that an SMI evaluation referral is warranted? 

For incarcerated individuals: 

  • Does the individual have a history of outpatient mental health treatment while not incarcerated? History of suicide attempts and psychiatric hospitalizations? What has been effective for managing their symptoms?

Once you have determined that a referral is appropriate, we highly encourage you to provide the evaluator with all behavioral health records that you can obtain (from current or previous providers), including psychiatric assessments and progress notes, other clinical or counseling notes, psychological/psychometric testing, medication list, and other documents that would support the above points.

SMI Evaluation Submissions

The points below are designed to assist providers in submitting a thorough evaluation so that this commitment can be met. 

  • Double check to ensure that ALL required forms are completed, signed, and dated prior to submission. Failure to do so may delay the determination 
  • If a behavioral health technician or other unlicensed assessor completes the evaluation, ensure that the appropriate supervisor reviews evaluation and signs off before submitting 
  • While an assessment is up to 6 months old, it may not reflect current symptoms and functioning, please submit a more recent assessment 
    • We strongly advise you to use the behavioral health assessment created by the RHBA, as it was created to capture relevant information needed to make a determination 
  • Submit treatment records if you have them, including the most recent psychiatric evaluation. 
  • It may be beneficial to extend (“pend”) the decision/determination in order to obtain additional records or to secure a face-to-face meeting or for 90 days to clarify recent substance use issues. 
    • Please attempt to provide the above options on the 3 Day Waiver form. 
  • In order to be determined eligible for SMI benefits, the criteria, as defined by AZ DBHS, must be well documented 
    • There must be at least one SMI-qualifying diagnosis in which the symptoms documented are consistent with the diagnostic criteria and information in the assessment and records.  
      • While you may list the actual DSM-IV diagnostic criteria that the individual meets, be sure to also include specific examples of symptoms, behaviors, quotes, and provider/assessor observations. 
        • Include type, onset, frequency, duration, and severity. In other words, explain how the symptoms are manifested in this individual.
        • Be as detailed as possible and avoid vague terms (i.e. “mood swings”).
      • If a person has an SMI-qualifying diagnosis with an “NOS” specifier (i.e. Mood Disorder NOS, Psychotic Disorder NOS, etc), please explain why a more specific diagnosis has not been given and what other diagnoses the provider may need to rule out or consider. 
    • There must be at least one area of Functional Impairment that is due to the Qualifying Diagnosis (for at least 12 months or 6 months with an expected continued duration of another 6 months).  
      • Explain how the diagnosis directly linked to the impairment and how the duration criterion is met.  
      • If the person has additional conditions that are not SMI-Qualifying Diagnoses (including but not limited to: Substance Use/Dependence, a head injury or TBI, Chronic Pain, a Pervasive Developmental Disorder, Mental Retardation, Eating Disorder, Antisocial Personality Disorder, Conduct Disorder, ADHD, Mood Disorder due to General Medical Condition, Adjustment Disorder, incarceration/legal issues, other stressors), then please explain how their functional impairment is primarily caused by the qualifying SMI diagnosis and not those other conditions or stressors. 
  • If there is a history of (or current) substance use, explain whether there is evidence of periods of sustained sobriety and persistence of symptoms and functional impairment during those periods. 
    • Submit UDS results as well. 
  • Explain the individual’s treatment history. 
    • What has been successful? 
    • Can the individual obtain services through a GMH/SA provider?  
      • If so, what services does the treating provider believe the person requires that the GMH/SA provider cannot offer? 
  • Explain clearly the history of DTS/DTO behaviors, hospitalizations/COE/COT, and family history of mental illness. 
  • Occasionally, providers may be asked to submit an SMI Evaluation for an individual even when the provider does not believe that SMI criteria are fully supported at that time. 
    • Please ensure that you document this accurately and explain the reason for the referral.