6 NHSC Comprehensive Behavioral Health Services Checklist

OMB Number: 0915-0127

Expiration Date: xx/xx/xxxx

Bureau of Health Workforce

U.S. Department of Health and Human Services Health Resources and Services Administration

NHSC COMPREHENSIVE BEHAVIORAL HEALTH SERVICES CHECKLIST

Attach all required documentation for services provided on-site and off-site

**Only NHSC Site Administrators are permitted to submit certification document**

Name of Site

Address

Section I. Core Comprehensive Behavioral Health Services The following three services must be provided on-site; these services cannot be offered in-network or off-site through referral, affiliation, or contract. Sites must provide documentation demonstrating that these services are provided on-site. Refer to the Site Reference Guide for the on-site document list.	Check the box and enter supporting documentation
	Provided On-site	What document demonstrates this service?
1. Screening and Assessment: Screening is the practice of determining the presence of risk factors, early behaviors, and biomarkers which enables early identification of behavioral health disorders (e.g., warning signs for suicide, substance abuse, depression) and early access to care. Assessment is a clinical examination that analyzes bio-psych-social information to evaluate patient behavioral health.		Click or tap here to enter text.
2. Treatment Plan: A formalized, written document that details a patient's current clinical symptoms and diagnosis, and outlines the therapeutic strategies and goals that will assist the patient in reducing clinical symptoms and overcoming behavioral health issues. The plan also identifies clinical care needs and treatment(s) to be provided by affiliated health and behavioral health care providers and settings.		Click or tap here to enter text.
3. Care Coordination: Care Coordination is the practice of navigating and integrating the efforts of primary care, specialty health care, and social service providers to support a patient’s health, Wellness and independence.		Click or tap here to enter text.

Section II. Non-Core Comprehensive Behavioral Health Services The following services may be provided on-site, in-network, or off-site through referral, affiliation, or contract. Sites must provide documentation demonstrating that these services are provided on-site, in-network, or off-site. Refer to the Site Reference Guide for the on-site and off-site document list.	Select On-site or Off-site and enter supporting documentation
	(Select One)		What document demonstrates this service?
	On-Site	Off-Site
1. Diagnosis: The practice of determining a patient’s emotional, socio-emotional, behavioral, or mental symptoms as a diagnosable disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM; most current edition) and International Classification of Disease (ICD; most current edition).			Click or tap here to enter text.
2. Therapeutic Services (including, but not limited to, psychiatric medication prescribing and management, chronic disease management, and Substance Use Disorder Treatment): Broad range of evidence-based or promising behavioral health practice(s) with the primary goal of reducing or alleviating behavioral health symptoms, improve functioning, and restore/maintain a patient’s health (e.g., individual, family, and group psychotherapy/counseling; psychopharmacology; and short/long-term hospitalization).			Click or tap here to enter text.
a. Psychiatric Medication Prescribing and Management			Click or tap here to enter text.
b. Substance Use Disorder Treatment			Click or tap here to enter text.
c. Short/long-term hospitalization			Click or tap here to enter text.
d. Other (Please list)			Click or tap here to enter text.
e. Other (Please list)			Click or tap here to enter text.
3. Crisis/Emergency Services (including, but not limited to, 24-hour crisis call access): The method(s) used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems. In some instances, a crisis may constitute an imminent threat or danger to self and others or a grave disability. (Note: generic hotline, hospital emergency room referral, or 911 is not sufficient).			Click or tap here to enter text.
4. Consultative Services: The practice of collaborating with health care and other social service providers (e.g., education, child welfare, and housing) to identify the biological, psychological, medical, and social causes of behavioral health distress, to determine treatment approach(s), and to improve patient functioning.			Click or tap here to enter text.
5. Case Management: The practice of assisting and supporting patients in developing their skills to gain access to needed health care, housing, employment, social, educational, and other services essential to meeting basic human needs and consistent with their health care treatment, symptom management, recovery, and independent functioning.			Click or tap here to enter text.

Section III. Off-Site Behavioral Health Service Provider(s) For each of the non-core services under Section II that are provided off-site, enter the entity that provides the off-site service(s).
Provider’s Name	Click or tap here to enter text.	Provider’s Name	Click or tap here to enter text.
Address	Click or tap here to enter text.	Address	Click or tap here to enter text.
Services Offered	Click or tap here to enter text.	Services Offered	Click or tap here to enter text.
Provider’s Name	Click or tap here to enter text.	Provider’s Name	Click or tap here to enter text.
Address	Click or tap here to enter text.	Address	Click or tap here to enter text.
Services Offered	Click or tap here to enter text.	Services Offered	Click or tap here to enter text.

Section IV. Certification of Compliance with Behavioral Health Clinical Practice Requirements Certify that the behavioral health site adheres to the clinical practice requirements for behavioral health providers under the NHSC and supports NHSC participants in meeting their obligation related to the clinical practice requirements. Refer to the appropriate NHSC Application and Program Guidance for a detailed definition of Full-Time or Half-Time Clinical Practice.	Site Meets Criteria (Select One)
	YES	NO
Full-time: The site offers employment opportunities that adhere to the NHSC definition of full-time clinical practice.
Half-time: The site offers employment opportunities that adhere to the NHSC definition of half-time clinical practice.

Section V. Site Certification

By signing below, the NHSC Site Administrator is affirming the truthfulness and accuracy of the information in this document.

I, , hereby certify that the information provided above, and all supporting

information, is true and accurate. I understand that this information is subject to verification by the NHSC.

Signature

Date: Click or tap here to enter text.

OFFICIAL USE ONLY
Recommended By:	Certified	Not Certified
Comments:

Public Burden Statement

The purpose of this information collection is to obtain information through the National Health Service Corps (NHSC) Loan Repayment Program (LRP), NHSC Substance Use Disorder (SUD) Workforce LRP, and the NHSC Rural Community LRP applications, which are used to assess an LRP applicant’s eligibility and qualifications for the LRP and to obtain information for NHSC site applicants. Clinicians interested in participating in a NHSC LRP must submit an application to the NHSC to participate in one of the NHSC programs, and health care facilities must submit an NHSC Site Application and Site Recertification Application to determine the eligibility of sites to participate in the NHSC as an approved service site. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0127 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (Section 333 [254f] (a)(1) of the Public Health Service Act). Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].