PROVIDER NAME: Enter the provider/licensee name shown
on the Group Home Program Rate Application (SR 1).
PROGRAM NUMBER: For an Annual or Program Change,
enter the number previously assigned by DSS. For an Initial,
leave blank.
MONTH/YEAR: Month and year for hours worked.
MENTAL HEALTH PROFESSIONAL: List names of all
mental health professionals (payroll or contract) who are
providing treatment services for the month. Professional staff
providing treatment services may be one of the following:
psychiatrist, psychologist, LCSW, MFT, or other level.
COLUMN A - DIRECT MENTAL HEALTH HOURS WORKED
QUALIFYING/REPORTED
Enter the number of hours of mental health services
provided, either individually to a child or to a group
of children.
COLUMN B - VERIFIED HOURS
Providers do not complete. For FCARB use only.
COLUMN C - REPORTED PROFESSIONAL WEIGHTINGS
Enter the reported professional weighting for each
staff.
COLUMN D - MENTAL HEALTH PROFESSIONAL LEVEL
Enter the weighting for each staff member
according to his/her respective professional level.
Example: If the service is provided by a
psychiatrist, enter 5.0 points under Column (B) -
Psychiatrist.
COLUMN E - TOTAL MENTAL HEALTH WEIGHTED HOURS
Multiply Column A times Column C, enter the total.
COLUMN A - TOTAL
Enter the total Direct Mental Health Hours worked;
transfer to SR 2, Column (8).
COLUMN E - TOTAL
Enter the Total Weighted Hours; transfer to SR 2,
Column (9).
INSTRUCTIONS TO COMPLETE MENTAL HEALTH
COMPONENT PROGRAM WORKSHEET (SR 2C)
