Ancillary Service One-to-One (1:1) Request Form YOUTH 2026

1. Click ‘Get Form’ to open the Ancillary Service One-to-One (1:1) Request Form YOUTH in the editor.
2. Begin by filling out the Youth Information section, including the youth's name, Customer ID, and Date of Birth.
3. In Section 1, provide a Clinical Justification detailing why this service is necessary. Include specific behaviors of concern and goals for One-to-One support.
4. Next, outline the Clinical Plan by describing interventions that will be implemented to address identified behaviors and goals.
5. Indicate the Requested number of hours per day (up to eight hours) and specify the duration and times when support will be available.
6. Complete your information in the Completed By section, including your email, signature, title, agency, phone number, fax number, and date.
7. Proceed to Section 2 for input from the Family Guidance Center Clinical Lead. They will indicate their support for One-to-One services and any plans to decrease hours if necessary.
8. Finally, Section 3 must be completed by the CSO Resource Manager who will recommend approval based on provided details.

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