MDHHS-6089, Psychiatric Residential Treatment Facility (PRTF)

and Intensive Community Transition Services (ICTS)

Michigan Department of Health and Human Services (MDHHS)

Division of Adult Home and Community Based Services

(Revised 6-24)

Requesting Agency

Recipient Name	Date of Birth

Date of Program Entry	Legal Status	Next Individual Plan of Service (IPOS) Meeting

Legal Status Non applicable TCW PCW MCI Ward NGRI Other

Extension Request 30 Days 60 Days 90 Days

Diagnosis

Clinical Reasoning for Extension Request

Current Permanency/Placement Plan

Attached Documentation Current Treatment Plan Medication List Incident Reports (Not already sent) Other

Signature of Requestor	Date

for prtf/icts completion only

Extension Approved End Date

Denied Reason

Date of Denial

Signature of PRTF/ICTS Approver	Date

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.