PEER Support Services (PSS) Referral Form

Please fill out the following form: 

1. MEMBER DEMOGRAPHICS & ELIGIBILITY

SMI/SUD w functional impairment

2. CCA DOCUMENTATION SUMMARY (QP to complete)

Clear Signature
(≤80 units/week total)

3. PERSON-CENTERED PLAN PSS GOALS (3 max)

4. REFERRING PROVIDER / DISCHARGE PLANNER

Clear Signature

5. LME/MCO AUTHORIZATION TRACKING

Clear Signature