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Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Form
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)



Form
F800-081-000
 
Crime Victims Compensation Program Progress Note: Form III

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.



Form
F800-082-000
 
Crime Victims Compensation Program Treatment Report: Form IV

Used by the clinical provider to request preauthorization for payment of additional sessions.



Form
F800-083-000
 
Crime Victims Compensation Program Treatment Report: Form V

Used by the clinical provider to get preauthorization for payment of additional sessions.



Form
F800-084-000
 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

Used by immediate family members of homicide victims to request mental health counseling.



Form
F800-057-909
 





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