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Child 0 5 Behavioral Health Screening Form for Assessment and Treatment as Medically Necessary MEMBER INFO Patient Name: Date of Birth: / / M F Medical # (IN): Current Eligibility: Language/cultural
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What is child 0 - 5?
Child 0-5 refers to a child who is between the ages of 0 and 5 years old.
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Parents or legal guardians of children aged 0-5 are required to report information about them.
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To fill out information about child 0-5, parents or legal guardians need to provide details such as name, date of birth, and relationship.
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