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Serious Emotional Disturbance (SED) Verification FormName: __________________________________ Date of Birth: ___________ Medicaid CIN: _________Select at least one DSM Qualifying Mental Health Category*:Current Diagnosis (ICD-10):Anxiety Disorders Bipolar and Related Disorders Depressive Disorders Disruptive, Impulse-Control, and Conduct Disorders Dissociative Disorders Obsessive-Compulsive and Related Disorders Feeding and Eating Disorders Gender Dysphoria Paraphilic Disorders Personality Disorders Schizophrenia Spectrum and Other Psychotic Disorders Somatic Symptom and Related Disorders Trauma- and Stressor-Related Disorders ADHD Elimination DisordersSleep Wake DisordersSexual DysfunctionsMedication Induced Movement DisordersTic Disorder*Any diagnosis in these categories can be used when evaluating a child for SED. However, any diagnosis that is secondary to another medical condition is excluded.Functional Limitation(s) within the last 12 months, on a continuous or intermittent basis: (Select all that apply & severity, must have at least 2 moderate or 1 severe to qualify)ModerateSevereAbility to care for self (e.g. personal hygiene; obtaining and eating food; dressing; avoiding injuries)Family life (e.g. capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting)Social relationships (e.g. establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time)Self-direction/self-control (e.g. ability to sustain focused attention for a long enough period of time to permit completion of age-appropriate tasks; behavioral self-control; appropriate judgment and value systems; decision-making ability)Ability to learn (e.g. school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school)I hereby attest, to be a treating and/or assessing Licensed Practitioner of the Healing Arts (LPHA) that has determined the child/youth above meets the clinical standards for Serious Emotional Disturbance (SED).Name of Licensed Practitioner: ___________________________________________________________Organization/Practice Name: _____________________________________________________________NPI/License #:_________________________________________________________________________Licensed Practitioner Signature: __________________________________________________________Date: __________________Additional Comments (if needed):
What diseases cause anxiety? There are several types of anxiety disorders, including: Generalized anxiety disorder (GAD). Panic disorder. Phobias. Separation anxiety.