DELAWARE HEALTH AND SOCIAL SERVICES Division of Substance Abuse and Mental Health COMMUNITY SUPPORT PROGRAM Certification Form Part I Completed by Screening Agency Consumer Name: Last First M.I. Consumer MCI# D.O.B. / / (10 digits) mm dd year CSP Provider referred to: Date Referred: / / Authorized Agency Representative: Part II Physician Certification (CSP Program completes 60 days after admission) CSP Program Name: Admission Date: / / Certification Due Date / / (60 days later) Based on the indications of the Delaware Assessment Packet completed on / / and my examination of / / documented in the client record, I hereby certify that the provision of the following community support rehabilitation services , medically necessary for the above named consumer. (are) (are not) CTT Level I CTT Level II Other Licensed MH Group Home Medicaid Yes No Certification Effective Date: / / End Date: / / Physician Signature: Date: / / Part III Screening Agency Review of Certification (completed by CMHC) (Due 15 days after recertification) The physician’s certification and the Delaware Reassessment Packet have been reviewed by the Community Mental Health Center and found to be complete. Agency Authorized Representative Signature: Date: / / Authorized Units: Authorized Months/Days: DSAMH Revised 12/02 CSP-CERT.DOC