ࡱ>   bjbj## 3AAiFpHrr8. DL$hf'(''*999~~~~~~~$΄~989@99~rr'* 'J'J'J9r'R*~'J9~'J'Jt8zhy*0jS<.v,~0L w<Xyy8z99'J99999~~B999L9999999999999 8:    Child Specific Staffing Team (CSST) Facilitators by County Please send your completed packet with supporting documentation to the individuals below according to which county you and your child reside in.  Suncoast Regions Childrens Mental Health Community Providers All children should be receiving Targeted Case Management (TCM) services prior to and throughout their residential program Charlotte CountyCharlotte Behavioral Health CareGina Wynn(941) 639-8300 ext. 2497Jean Tucker(941) 639-8300 ext. 2309Collier CountyDavid Lawrence CenterSusan Kirgan(239) 451-6215Cindy Burman(239) 451-6178Hillsborough CountyBNET Caring Community CounselingDelilah Fortenberry Main Office (813) 722-2882 (727) 367-2273CFBHN (For Staffings Only) Chrysalis HealthJennifer Fitzgerald Hillsborough Office(813) 740-4811 ext. 260 (813) 443-4827Life Share Management GroupAlexandria Wright(813) 891-9474Success 4 Kids & FamiliesEdna Pizano(813) 490-5490 ext. 221Lee CountySalus CareSalvatore Romano(239) 275-3222, ext. 1066Kristen Davis(239) 791-1517Manatee CountyCenterstone Ann Burke(941)782-4225Charles Whitfield(941)782-4203Pinellas CountyAdoption Related Services of PinellasEmail: referral@arsponline.org(727) 657-7761Camelot Caring Community Counseling Chrysalis HealthDawn White Main Office Referrals-north@chrysalishealth.com(727) 593-0003 ext. 1101 (727) 367-2273 (727) 231-4885Directions for LivingShianne Hall(727) 270-1127 (727) 547-4566 ext. 4411Suncoast Regions Childrens Mental Health Community Providers Continued Pinellas County Cont. PEMHS Beth Lewis (727) 545-6477 ext. 333Sequel Care of FloridaKate Malcolm Juan Costanza(727) 547-0607 ext. 116 (727) 547-0607 ext. 123Suncoast Center for Community Mental HealthJulio Burgos Lisa Signorelli(727) 327-7656 ext. 4161 (727) 327-7656 ext. 6503 Pasco CountyBayCare Behavioral HealthSarah Cobelli(727) 834-3959 ext. 318849 Caring Community Counseling Chrysalis HealthTerri Turza Main Office Referrals- north@chrysalishealth.com(727) 834-3959 ext. 816714 (727)367-2273 (352) 205-4788 Sequel Care of Florida Sherri Albaum (727) 422-8431Carisa Fleissner(727) 494-7609David Dohm(727) 494-7609 ext 7003 Sarasota & Desoto CountiesCoastal BehavioralErica Barker(941) 492-4300 ext 2132Desoto Psychiatric Crisis 941.575.0222(941) 639-8300Providence Human Services of FloridaCounseling/TBOS/Med(941) 359-1927 Polk, Highlands & Hardee CountiesChrysalis Health Peace River CenterReferrals-north@chrysalishealth.com Tiffany Fritzche863-216-5636 (863) 519-0575 ext. 6235 (863) 519-0575 ext. 1105Angela Jones (CAT Team)(863) 512-0542TriCounty Human ServicesKitty Slark(863) 452-0106Winter Haven HospitalMaureen McIntire(863) 293-1121 Child Specific Staffing Team (CSST) Checklist Childs Name: __________________________________________________________ Date of Birth: ________________ County of Residence: ______________________ It is highly recommended that all of these items and supporting documentation are in the complete packet before mailing to the CSST Facilitator to prevent delay in the process. If any of these items do not apply to your child, please indicate this with N/A for not applicable. The following item must be submitted to the CSST facilitator to proceed with a residential referral.  FORMCHECKBOX  A Psychiatric or Psychological Evaluation with recommendation for Statewide Inpatient Psychiatric Program or Group Home level of care within the last year completed by a licensed psychologist or psychiatrist that must include: The child has an emotional disturbance as defined in Section 394.492(5), F.S., or a serious emotional disturbance as defined in Section 394.492(6), F.S.; The emotional disturbance or serious emotional disturbance requires treatment in a residential treatment center; please specify Statewide Inpatient Psychiatric Program for Medicaid funded/eligible children or Residential Treatment Center for Non-Medicaid funded children or Specialized Therapeutic Group Care, All available treatment that is less restrictive than residential treatment has been considered or is unavailable; The treatment provided in the residential treatment center is reasonably likely to resolve the childs presenting problems as identified by the licensed psychologist or psychiatrist; The treatment facility is qualified by staff, program and equipment to give the care and treatment required by the childs condition, age, and cognitive ability; The child is under the age of 18; and The nature, purpose and expected length of the treatment Stay has been explained to the child and the childs parent or guardian.  FORMCHECKBOX  A letter completed by the licensed psychologist or psychiatrist stating need for Therapeutic Group Home level of care or Statewide Inpatient Psychiatric Program level of care based on above criteria. The letter must include the criteria stated above and how that level of care will benefit the child.  FORMCHECKBOX  Previous Clinical Information which includes the following: Previous Clinical Information (i.e., admission reports, evaluations, discharge summaries) from Baker Acts, Residential & Inpatient Admissions, Partial Hospitalizations, Outpatient Treatment, etc.  FORMCHECKBOX  Completed Children Specific Staffing Team (CSST) Application with release of information forms completed  FORMCHECKBOX  Completion of Summary Form in back of application for any waived staffing with program of choice identified.  FORMCHECKBOX  Medical & School Records (Please include physical and any medical records information that would be pertinent to treatment).  FORMCHECKBOX  Copy of Birth Certificate and Social Security Card  FORMCHECKBOX  Immunization Records  FORMCHECKBOX  Medical Stability Clearance and Dental Clearance -Physical within last 90 days  FORMCHECKBOX  IEP, if in Special Education (ESE Classification) or last Report Card, if Regular Education Most Recent IQ Score with supported documentation  FORMCHECKBOX  DJJ JJIS History Form (If Applicable) JPO Name________________________________ Phone # _____________________  FORMCHECKBOX  Identification of a Targeted Case Manager (TCM) in Parent/Guardian County TCM Name_______________________________ Phone # __________________________ Adoption Related Specialist: _________________________________________________  FORMCHECKBOX  Please check to ensure packet is complete before sending to CFBHN Reviewed by: _____________________________________Date: __________________ Complete: ______________ Incomplete: ___________ Pre-Admission Medical Questionnaire for SIPP Admission Name of Client: _________________________________________________ DOB: ___/___/____ Date of last Physical Check-Up: ____________________ Date of Last Dental Check-Up: __________________ Has the child had a medical illness or injury since the last check up: Yes/No If yes, please explain: _________________________________________________________________________ Has the child visited a doctor other that his/her primary care provider in the last two years or was the child referred to a specialist even if an appt was never made? Yes/No If yes, please explain: _________________________________________________________________________ Has a physical ever denied/restricted the childs participation in sports or activities for any heart problems? Yes/No If yes, please explain: _________________________________________________________________________ Does the child have any active of medical condition or chronic illness? This can include but not limit: asthma, seizures, high blood pressure, HIV, Hepatitis B or C, sickle cell, heart disease, diabetes, etc. Yes/No If yes, please explain: __________________________________________________________________________ Does the child cough, sneeze, wheeze, or have trouble breathing during or after physical activity? Yes/No Has the child ever been diagnosed with a developmental disorder/ learning disability/ Autism? Yes/No If yes, please explain: __________________________________________________________________________ Was the child ever involved in a car accident that resulted in injuries? Yes/No If yes, please explain: __________________________________________________________________________ Has the child ever has a head injury, concussion, lost consciousness or memory? Yes/No If yes, please explain: __________________________________________________________________________ Has the child suffered any broken or fractured bone(s) or dislocated any joint(s)? Yes/No If yes, please explain: __________________________________________________________________________ Does the child use any special protective/corrective equipment or medical devices such as glasses, knee/neck brace, shunt, and retainer on the teeth or hearing aid? Yes/No If yes, please explain: __________________________________________________________________________ If female, is pregnancy suspected or confirmed? Yes/No Due date (if known): ________________ Is Depo Provera injections used for birth control? Yes/No If yes, date of the last injection: ____________________ Is the child currently taking any prescription or any non-prescription (over-the-counter) medications? Yes/No If yes, list all medications that the child is taking at this time, including vitamins: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________ _______________________________________ Name of Person completing this Form (Print) Relation to Client ________________________________________ _______________________________________ Signature of Person completing this form Phone Number Child Specific Staffing Team (CSST) Application Childs Name: ______________________________________ DOB ____/____/____ Age___________ Parent/Legal Guardian: _______________________________ Phone: _____________________________ Full Address: ___________________________________________________________________________ Sex: ____ Race: ________ Ethnicity ____________Does the child have Medicaid? ___Yes ___No Name of Florida Medicaid Managed Medical Assistance Program Plan (MMA): _______________________________________________________________________________________ Medicaid Plan/number ______________ Social Security Number __________________________________ Current Placement (circle or check): ____ Parent home ____Juvenile Detention Center ___Crisis Stabilization Unit ____Residential Placement ____Shelter Adopted ____Yes _____ No Adoption Agency _________________________________________________ If yes, on what date did the adoption occur? ____________What state? ________________________ Since the adoption, have you received support and or services from an Adoptions Preservation Worker? ______ Yes ______ No If so, please provide the contact information _______________________________________________ Are you receiving an adoption subsidy? _______Yes ______No If so, list the amount.__________________________________________________________________ Is the child receiving social security benefits? _____ Yes ______ No If so, please list the amount ____________________________________________________________ Are you receiving any other financial support from any agency, government entity, or other party on behalf of the adoption? _____Yes ________No Do you have other adopted children in your home? If so, please describe the age, date of adoption and financial support provided. _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ School: ________________________________________________________ Grade: _____________ Current school classification: _______________________________________ Full scale IQ: ________ Diagnosing Clinician/Credentials: ___________________________________ Date of DX: __________ Current DSM IV DiagnosisCurrent Medications/ Dosage /FrequencyAxis I:Axis II:Axis III:Axis IV:Axis V: Are you involved in Targeted Case Management at this time: Yes _____ No ____ If you are involved in Targeted Case Management who are you receiving services from ____________________________________________________________________________________ Past and current treatment provided (check all applicable): ____Targeted Case Management ____Out Patient Counseling ____Medication ____TBOS (in-home therapy) ____ Dept. of Juvenile Justice ____Substance Abuse Treatment ____Crisis Stabilization Presenting problems of concern: ____________________________________________________________________________________ Doctor and/or Clinicians recommendations: ____________________________________________________________________________________ Parent Signature: _________________________________________ Date: ______________________ Phone: ____________________________ Case Manager/Therapist Signature: ___________________________ Date: ___________________ Child Specific Staffing Team (CSST) Case Summary Childs Name: ______________________________________ Date of Birth: ______________ Childs strengths: ______________________________________________________________________________________________________________________________________________________________________________ Significant history (i.e. abuse, neglect, exposure to domestic violence, substance abuse, etc.): ______________________________________________________________________________________ ______________________________________________________________________________________ Current services involved: ______________________________________________________________________________________________________________________________________________________________________________ Medical issues/over the counter medications used regularly: ______________________________________________________________________________________________________________________________________________________________________________ Placements out of home (i.e. residential placement, crisis stabilization admissions): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Legal involvement (Dept. of Juvenile Justice and/or Dept. of Children & Families): Has your child had ANY involvement with the criminal justice system? If so, please list the date, charge, and disposition.__________________________________________________________ Prior to packets being disseminated to providers, parents/guardians will need to contact the DJJ and obtain a copy of the DJJ JJIS form. This form can be obtained from your childs juvenile probation officer or local detention facility. __________________________________________ Please provide the juvenile probation officers name and contact information: _______________________________________________________________________________ Behavioral symptoms (actions of child): ______________________________________________________________________________________________________________________________________________________________________________ Family issues/supports: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What parents/guardian is requesting: ______________________________________________________________________________________________________________________________________________________________________________ Signature of person completing summary: ____________________________________________________________________________________ Relationship to child: ___________________________________________________________________ Date: _______________________________________________________________________________ Family Support Services and Advocacy Services Sarasota Sarasota Family Support Network Phone: (941) 371-8820 Email:  HYPERLINK "mailto:kelly.lewin@thefloridacenter.org_" kelly.lewin@thefloridacenter.orgTampa Hillsborough County FFCMH Larry English Phone: (813) 974-7930 Email:  HYPERLINK "mailto:ffcmh@earthlink.net_" ffcmh@earthlink.net  HYPERLINK "http://www.federationoffamilies.org/_" www.federationoffamilies.org Tampa Familias Latinas Deman Huellas-Capitula Luz Garay Phone: (813) 245-4820 Email:  HYPERLINK "mailto:dejandohuellas2004@gmail.com_" dejandohuellas2004@gmail.comNational Alliance on Mental Illness (NAMI) Provides support, education and advocacy for persons living with mental illness and their parents, families and friends.  HYPERLINK "http://www.nami.org/Template.cfm?Section=Your_Local_NAMI&Template=/CustomSource/LocalDetail.cfm&localID=0000000584&fromHL=no&state=FL_" NAMI Hillsborough Nicole Shiber (813)273-8104 HYPERLINK "http://www.nami.org/Template.cfm?Section=Your_Local_NAMI&Template=/CustomSource/LocalDetail.cfm&localID=0000000287&fromHL=no&state=FL_" NAMI Collier County Pam Baker (239)434-6726 NAMI PascoInformation/Referral Line: (727) 992-9653  HYPERLINK "http://www.nami.org/Template.cfm?Section=Your_Local_NAMI&Template=/CustomSource/LocalDetail.cfm&localID=0000000629&fromHL=no&state=FL_" NAMI Pinellas County Ajoy Kumar (727)209-0890 NAMI Of Sarasota Barry Jeffrey (941)957-3626 Multiagency Network for Students with Emotional Disabilities (SEDNET) Services SEDNET can assist in the transitioning of residentially placed students back into the home and community. SEDNETs primary focus is on enhancing the system of care for families and children in their natural environments whenever possible  HYPERLINK "http://www.nami.org/Template.cfm?Section=Your_Local_NAMI&Template=/CustomSource/LocalDetail.cfm&localID=0000000584&fromHL=no&state=FL_" SEDNET Hillsborough Nanci Nolan Success 4 Kids & Families (813) 490-5494 ext. 212  HYPERLINK "mailto:nnolan@s4kf.org" nnolan@s4kf.org SEDNET Pinellas/Pasco Melissa Andress (727) 669-1220 ext. 2024  HYPERLINK "mailto:andressm@pcsb.org" andressm@pcsb.org SEDNET Hardee/Highlands/Polk Tracey Dasher (863) 534-0930  HYPERLINK "mailto:tracey.dasher@polk-fl.net" tracey.dasher@polk-fl.net  Parent/Legal Guardian Authorization for the Release of Information Name of Child: _______________________________________ Date of Birth: __________________________ I (We) hereby authorize ________________________________________ to release a copy of the information (Agency name) Specified below: [ ] School Records [ ] Department of Juvenile [ ] Medical History (physical and lab work) [ ] Records of intervention [ ] Psychiatric/Psychosocial evaluations and information [ ] Clinical Records [ ] Hospital Records psychiatric [ ] other(s) Please describe: ________________ [ ] Neurological evaluation TO THE AGENCY/CSST FACILITATOR CHECKED BELOW & THE MEMBERS OF THE CSST: [ ] Pasco County: [ ] Sarasota & Desoto Counties: [ ] Charlotte County: ATTN: Therese Turza ATTN: Erica Barker ATTN: Gina Wynn BayCare Behavioral Health Coastal Behavioral Health Charlotte Behavioral Health Care Phone: (727) 834-3959 x 318862 Phone: (941) 492-4300 Phone: (941) 639-8300 ext. 2497 Fax: (727) 834-3969 Fax: (941) 492-2170 Fax: (941) 639-6831 [ ] Hillsborough County: [ ] Lee County: [ ] CFBHN: ATTN: Jennifer Fitzgerald ATTN: Salvatore Romano 719 US Highway 301 South CFBHN SalusCare Inc. Tampa, FL 33619 Phone: (813) 740-4811 ext. 260 Phone: (239) 275-3222 Phone: (813) 740-4811 Fax: (813) 740-4821 Fax: (239) 989-2891 Fax: (813) 740-4821 [ ] Manatee County: [ ] Pinellas County: [ ] Hardee, Highland, and Polk ATTN: Charles Whitfield ATTN: Shianne Hall ATTN: Tiffany Fritzche Centerstone Directions for Living Peace River Center Phone: 941-782-4203 Phone: (727) 270-1127 Phone: (863) 519 0575, ext. 6235 Fax: (941) 782-4112 FAX: (727) 547-4599 Fax (863) 863-519-0528 [ ] Collier County: [ ] Winter Haven Hospital ATTN: Susan Kirgan ATTN: Maureen McIntire David Lawrence Center Phone: (863) 293-1121 Phone 239 455-8500 ( ) Other _________________ Fax #239 643-7278 FOR THE PURPOSE OF: Determination of the most appropriate community services and/or residential treatment for the above child and for the approval of funding for recommended treatment. I understand that the information obtained will become part of the application for referral of the above-named child to CSST. If the committee determines that the child is appropriate for a referral to a residential treatment facility and/or community services, I understand that the complete application and packet of records will be forwarded by Central Florida Behavioral Health Inc. to any/all facilities recommended by the committee for consideration for that program. This release is valid for one (1) year from the date of consent. I understand that consent may be revoked through written request at any time. I have read, or have had verbally explained to me, the above authorization and fully understand it. I hereby, release Central Florida Behavioral Health Inc. and CSST from any liability that may arise as a result of the use of the information contained in the records released. Signature of Legal Guardian: _______________________________________ Date: ___________ Relationship to Child: _____________________________________________ Signature of Witness: _____________________________________________ Date: ____________________________________________________________________________ Parent/Legal Guardian Authorization for the Release of Information to Florida Managed Medical Assistance Program (MMA) for Children with Medicaid Name of Child: _________________________________________________ Date of Birth: ___________________ I (We) hereby authorize Central Florida Behavioral Health Network, Inc. to release a copy of the information Specified below: [ ] School Records [ ] Department of Juvenile [ ] Medical History (physical and lab work) [ ] Records of intervention [ ] Psychiatric/Psychosocial evaluations and information [ ] Clinical Records [ ] Hospital Records psychiatric [ ] other(s) Please describe: ____________________ [ ] Neurological evaluation ___________________________________________ TO: Florida Medicaid Managed Medical Assistance Program (MMA) Plan below: [ ] Amerigroup Florida, Inc. [ ] Better Health [ ] Integral [ ] Humana [ ] Prestige [ ] Sunshine [ ] United [ ] Molina [ ] Staywell [ ] Psychcare [ ] WellCare [ ] Cenpatico FOR THE PURPOSE OF: Determination of the most appropriate community services and/or residential treatment for the above child and for the approval of funding for recommended treatment. I understand that the information obtained will become part of the application for referral of the above-named child to CSST. If the committee determines that the child is appropriate for a referral to a residential treatment facility and/or community services, I understand that the complete application and packet of records will be forwarded by the Central Florida Behavioral Health Inc. to any/all facilities recommended by the committee for consideration for that program. This release is valid for one (1) year from the date of consent. I understand that consent may be revoked through written request at any time. I have read, or have had verbally explained to me, the above authorization and fully understand it. I hereby, release Central Florida Behavioral Health Network Inc. and CSST from any liability that may arise as a result of the use of the information contained in the records released. Signature of Legal Guardian: _______________________________________ Date: _______________________ Relationship to Child: ___________________________________________________________________________ Signature of Witness: _____________________________________________ Date: _______________________ Parent/Legal Guardian General Authorization for the Release of Information Name of Child: _______________________________________ Date of Birth: __________________ I (We) hereby authorize Central Florida Behavioral Health Network _ to release a copy of the information (Agency Name) Specified below: [ ] School Records [ ] Department of Juvenile [ ] Medical History (physical and lab work) [ ] Records of intervention [ ] Psychiatric/Psychosocial evaluations and information [ ] Clinical Records [ ] Hospital Records psychiatric [ ] other(s) Please describe [ ] Neurological evaluation __________________________________ TO: Name of Individual and relationship to Parent/Legal Guardian Below _________________________ ____________________________________________________________________________________ FOR THE PURPOSE OF: Determination of the most appropriate community services and/or residential treatment for the above child. This release is valid for one (1) year from the date of consent. I understand that consent may be revoked through written request at any time. I have read, or have had verbally explained to me, the above authorization and fully understand it. I hereby, release Central Florida Behavioral Health Network Inc. and CSST from any liability that may arise as a result of the use of the information contained in the records released. Signature of Legal Guardian: ______________________________ Date: _______________________ Relationship to Child: __________________________________________________________________ Signature of Witness: _________________________________ Date: _____________________ Statement of Dental Stability Childs Name: ____________________________ Date of Birth: __________________ Social Security #: _________________________ I, ____________________________________, have examined the above child and have determined that he or she is currently in good physical health with no acute or chronic dental conditions requiring extensive dental treatment, and the need for dental care, other than routine, is not anticipated. __________________________________________ ___________________ Dentists Signature Date *** Please attach a copy of the dental records that have been completed within the last 6 months*** *** Only needed for SIPP Services *** Statement of Medical Stability Childs Name: _________________________ Date of Birth: ________________ Social Security #: ______________________ I, ____________________________________, have examined the above child and have determined that he or she is currently in good physical health with no acute or chronic conditions requiring extensive medical treatment, and the need for medical care, other than routine, is not anticipated. __________________________________________ ___________________ Physicians Signature Date ***Please include last physical exam and any documents that have been completed in the past 90 days. This document cannot be over 12 months/1 year old. *** *** Only needed for SIPP Services *** Consent to Release Confidential Information I, hereby, give my permission to the Central Florida Behavioral Health Network, Inc. to release a copy for the documents presented to the Childrens Services Staffing Team to the agency(ies) recommended by the team for consideration of placement in mental health or substance abuse treatment programs for: Name of Child: _______________________________ Childs Date of Birth: ___________________________ I, hereby, release the facility(s) from any liability which may arise as a result of the use of the information contained in the records released. ___________________________________ ______________________________ Name of Parent/Guardian Signature of Parent/Guardian ___________________________________ _______________________________ Telephone# Date Signed Witness: ________________________________________________________________________ CFBHN Representative: ___________________________________________________________ TO RECEIVING AGENCY (IES): PROHIBITON OF REDISCLOSURE: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS FOR WHICH CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE CLIENT/GUARDIAN PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THIS INFORMATION. TICE Childrens Specific Staffing Team (CSST) Targeted Case Management Referral Form Date: __________________ Childs Name: _________________ DOB: ____________ Medicaid #: _________________ Guardian Contact Name: _____________________________________________________ Address: __________________________________________________________________ Phone Number: _____________________________________________________________ Current Targeted Case Management Services Information: Write none in space below if no current TCM Services at this time: Agency: _______________________ TCM Name: ______________________Phone: ______________ Contact Information of Person making the request for TCM Services Name: ____________________________________________________________________________ Address: __________________________________________________________________________ Phone Number: ____________________________________________________________________ Placement where TCM Services is being requested: Name of Company: ____________________________________________________________________ Address: ____________________________________________________________________________ Phone Number________________________________________________________________________ To be completed by CFBHNs Clinical Program Specialist Date when referral was made: __________________________________________________________ Additional Comments: ________________________________________________________________ __________________________________________________________________________________ Statewide Inpatient Psychiatric Program (SIPP) Contact Information  BayCare SIPP (Pasco County) Contact: Joy Toscani or Elizabeth Galysh Email:  HYPERLINK "mailto:Joy.Toscani@baycare.org" Joy.Toscani@baycare.org or  HYPERLINK "mailto:Elizabeth.Galysh@baycare.org" Elizabeth.Galysh@baycare.org 8132 King Hellie Blvd New Port Richey, FL 34653 727-834-3965 Palm Shores Behavioral Health Center (Manatee County) Contact: Albert Distefano Email:  HYPERLINK "mailto:Albert.Distefano@uhsinc.com" Albert.Distefano@uhsinc.com 1324 37th Ave E Bradenton, FL 34210 941-782-1752 Has separate unit for children under 12 years old University Behavioral Center (Orange County) Contact: Teresa Morales Email:  HYPERLINK "mailto:Teresa.Morales@uhsinc.com" Teresa.Morales@uhsinc.com 2500 Discovery Drive Orlando, FL 32827 407-281-7000 Sexual reactive treatment Sandy Pines (Palm Beach County) Contact: Meghan Theodore/Joan Kernaghan Email:  HYPERLINK "mailto:Meghan.theodore@uhsinc.com" Meghan.theodore@uhsinc.com or  HYPERLINK "mailto:Joan.kernaghan@uhsinc.com" Joan.kernaghan@uhsinc.com 11301 S.E. Tequesta Terrace Tequesta, FL 33469 561-744-0211 Sexual behavior/trauma issues Spanish speaking program Has separate unit for children under 12 years old Devereux (Orlando) (Orange County) Contact: Kelianne Bayless Email:  HYPERLINK "mailto:Referral@devereux.org" Referral@devereux.org 6147 Christian Way Orlando, FL 32808 1-800-338-3738 Specialized Therapeutic Group Home (STGH) Contact Information  Carlton Manor (BOYS ONLY) (Pinellas County) Contact: Dave Hytner Email:  HYPERLINK "mailto:Dhytner@carltonmanor.org" Dhytner@carltonmanor.org 45 Westwood Terrace North St Pete, FL 33710 727-422-5742 Devereux (Orange County) Contact: Central Referral Unit (CRU) Email:  HYPERLINK "mailto:Referral@devereux.org" Referral@devereux.org 1-800-338-3738, press1, ext. 77130 Girls STGH 2330 Aurora Rd. Melbourne, FL 32935 321-610-1970 Boys STGH 1850 South Deleon Ave, Titusville, FL 32780 407-374-1950 Florida United Methodist Childrens Home Contact: Yolaine Cotel (Volusia County) Email:  HYPERLINK "mailto:Yolaine.Cotel@fumch.org" Yolaine.Cotel@fumch.org 51 Childrens Way Enterprise, FL 32725 (386) 668-4774 ext. 2304 **This is a co-ed facility** Child and Family Staffing Summary Family Invited Attendees (name and relationship): Reason family wants residential mental health treatment for their child in their own words (what benefits they hope their child will get from treatment): Choice of Program SIPP: 1. ____________________ 2. ________________________ 3. ______________________ TGH: 1. ___________________ 2. ________________________ 3. ______________________ Did the team present any available less restrictive treatment options that address the childs identified needs: Yes ___________ No___________ If yes, what treatment options? If other treatment options were recommended, what were the familys objections or reasons for continuing to request residential mental health treatment services? CFBHN- Additional Notes: Please Note: While staffing is always a best practice, there are times when caregivers have already gathered all the required information and the necessary referral and choose to waive the staffing. In those cases, (1) please use this form to record the reason why the family chose not to have a staffing and (2) any relevant information you might have about the child and family that would be of help to the Utilization Manager (UM).     Page  PAGE 25 of  NUMPAGES 25    Child Specific Staffing Team (CSST) Application Effective 11/01/2017 All information should be received prior to a child/family being scheduled for the CSST. Incomplete information may delay a child/family from being placed on the schedule. A completed packet with supporting documentation must be sent to the CSST Facilitator, according to which county the child and family reside in. Upon receipt of the complete packet, the facilitator will contact the family and schedule them for the next available staffing date. A Childrens Mental Health Residential Resource Guide can be acquired at the Central Florida Behavioral Health Network home page at  HYPERLINK "http://cfbhn.org/community-resources.asp" http://cfbhn.org/community-resources.asp or requested thru CFBHN at 813-740-4811 ext. 260, 297, and 258. The Child Specific Staffing Team is NOT FOR AN EMERGENCY PLACEMENT. The Team will read through the information provided by the family and assist the family in clarifying what has and has not worked therapeutically. The team may identify resources that are available in the community that have not been tried and would be appropriate and helpful for the family. The staffing team may be comprised of the following: Florida Medicaid Managed Medical Assistance Program (MMA) Representative, Central Florida Behavioral Health Network, Inc. or designee, Parent/ Guardian, Child, treating provider, and the parent/guardian invitees such as the Department of Juvenile Justice (DJJ), School Liaison (SEDNET), Family Advocate, or other persons invited by the family. If the child has Medicaid and the parent/guardian has a completed packet, the family may choose to waive the staffing process for SIPP programs (not for TGH programs or requests for PRNM (non-Medicaid funding). The packet should be sent to the facilitator with the provider choice and the decision to waive the staffing. For families who have Medicaid, the placement for residential services must be authorized by the individual Florida Managed Medical Program (MMA) prior to admission and each individual MMA plan will determine length of stay thru utilization management with each individual residential provider. For all Waived Staffings, please specify Program of Choice where guardian would like packet to be sent to for review and CSST application must be sent to Florida Managed Medical Program (MMA) Plan (MMA plan contact information is listed towards end of this application and below is information to get further information on Florida Managed Medical Program (MMA) Plan). Toll-free Helpline: 1-877-711-3662, TTY/TDD users ONLY calls 1-866-467-4970 or visit  HYPERLINK "http://www.flmedicaidmanagedcare.com" www.flmedicaidmanagedcare.com. Call Center Hours: Monday-Thursday 8 am - 8 pm; Friday 8 am - 7 pm. If you need Choice Counseling materials in large print, Audio or Braille, call the Helpline. Si ou bezwen informasion un Kreyol, tanpris rele: 1-877-711-3662. The goal of the Child Specific Staffing Team is to have your child placed in the least restrictive setting meeting his/her needs. The Suncoast Regions least restrictive out of home level of care is the Therapeutic Group Home. Non Residential Options are available in Pinellas, Hillsborough, Manatee/Sarasota/Desoto, Lee, Collier, and Polk/Hardee/Highland Counties thru Childrens Community Action Teams (CAT). Childrens Community Action Team (CAT) is a self-contained multi-disciplinary clinical team. CAT provides comprehensive, intensive community-based treatment to families with youth and young adults, ages 11-21, who are at risk of out-of-home placement due to a mental health or co-occurring disorder and related complex issues for whom traditional services are not adequate. The CAT Team provides family-centered services individualized according to the strengths and needs of the child and family. The team and family work together with a goal of supporting and sustaining the youth or young adult in the most appropriate environment. Services provided and/or coordinated by the team include: Psychiatric (evaluation and medication management), Therapy (individual, group and family) counseling, Case Management, Mentoring, Crisis intervention & 24/7 on-call coverage/support, Educational system advocacy, coordination and tutoring, Legal system advocacy and coordination, Parenting skills/behavior modification , Family support network development, Employment/Vocational services, Life Skills Development, Respite Services. The Following is a list of CAT (Community Action Team) Providers Collier County: David Lawrence Center (239) 455-8500 Hillsborough County: Gracepoint (813) 239-8453 Lee County: SalusCare Florida (239) 791-1584 Manatee, Sarasota, Desoto Counties: Centerstone (941) 782-4396 Pinellas County: Personal Enrichment Through Mental Health Services (727) 362-4255 Polk, Hardee, and Highland Counties: Peace River Center (863) 519-0575 x 1105 Pasco: BayCare (727) 315-8638 Medicaid & DCF Residential Options A) Specialized Therapeutic Group Home (STGH) is an intensive, community-based, psychiatric, residential treatment service designed for children and adolescents with moderate-to-severe emotional disturbances. STGH is designed for youth who are ready for a step-down from a SIPP or to avoid placement into a SIPP. The goal of a STGH is to enable a youth to self-manage and to continue to work towards resolution of emotional, behavioral, or psychiatric problems. STGH placement is generally 6-9 months. B) Statewide Inpatient Psychiatric Program (SIPP) is to stabilize a severely emotionally disturbed and/or psychiatrically unstable child in a short period, generally 2-6 months, within a restrictive and highly structured environment. This setting is appropriate only when least restrictive services have been attempted and have been unsuccessful. Children and adolescents meeting any one of the following criteria are not considered appropriate for care in a SIPP: Less intensive levels of treatment will appropriately meet the needs of the child or adolescent The primary diagnosis is substance abuse, mental retardation, or autism The recipient is not expected to benefit from this level of treatment The presenting problem is not psychiatric in nature and will not respond to psychiatric treatment The youth has a history of long standing violations of the rights and property of others A pattern of socially directed disruptive behavior (e.g. Gang involvement) is the primary presenting problem or remaining problem after any psychiatric issue has stabilized Recipients cannot be admitted to a SIPP if they have Medicare coverage, reside in a nursing facility or ICF/DD, or have an eligibility period that is only retroactive or are eligible as medically needy Lack of Medical Clearance from a physician for admission Families who are receiving Social Security Income benefits: Please see the reporting procedures for SSI about change in residence with your child entering residential treatment. SSI requires notification about change in residence which may cause possible repayment of any funds received if notification to SSI office is not received. Lee County ATTN: Salvatore Romano SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Phone 239.275.3222 ext. 1066, Fax 239.791.0111 Mobile 239.989.2891 E-mail: HYPERLINK "mailto:SRomano@SalusCareFlorida.org" SRomano@SalusCareFlorida.org Pinellas County ATTN: Shianne Hall Directions for Living 8823 115th Ave. North, Largo, FL 33773 Phone 727.547-4566 Fax 727.547.4599 Mobile 727.270.3586 Email:  HYPERLINK "mailto:shall@directionsforliving.org" shall@directionsforliving.org Sarasota & Desoto Counties ATTN: Erica Barker Coastal Behavioral Health 12497 Tamiami Trail, North Port, FL 34236 Phone 941.492.4300 ext. 2132 Fax 941.492.2170  HYPERLINK "mailto:EBarker@coastalbh.org" EBarker@coastalbh.org Polk, Hardee, Highland County ATTN: Tiffany Fritzsche P.O. Box 1559 Bartow, FL 33831-1559 Phone 863.519.0575 ext. 6235  HYPERLINK "mailto:tfritzsche@peacerivercenter.org" mailto:tfritzsche@peacerivercenter.org Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org  Collier County ATTN: Susan Kirgan David Lawrence Center 6075 Bathey Lane Naples, FL 34116 Phone 239.451.6215 Fax 239.643.7278  HYPERLINK "mailto:Email: susank@dlcmhc.com" Email: susank@dlcmhc.com Charlotte County ATTN: Gina Wynn Charlotte Behavioral Health Care 1700 Education Ave. Punta Gorda, FL 33950 Phone 941.639.8300 ext. 2497 Fax 941.639.6831  HYPERLINK "mailto:GWynn@cbhcfl.org" GWynn@cbhcfl.org Manatee County ATTN: Charles Whitfield Centerstone 371 Sixth Ave. West Bradenton, FL 34205 Phone 941.782.4203 Fax 941.782.4112 Email:  HYPERLINK "mailto:Charles.whitfield@centerstone.org" Charles.whitfield@centerstone.org Hillsborough County ATTN: Jennifer Fitzgerald 719 US 301 South Tampa, FL 33619 Phone 813.740.4811 ext. 260 Fax 813.740.4821 Email:  HYPERLINK "mailto:cmh@cfbhn.org" cmh@cfbhn.org Pasco County ATTN: Teri Turza, Sr. Targeted Case Manager CSST Facilitator for Pasco County BayCare Behavioral Health Phone 727.834.3959 ext. 816714  HYPERLINK "mailto:Therese.turza@baycare.org" Therese.turza@baycare.org Youth and Family Alternatives, Inc. 7524 Plathe Road, New Port Richey, FL. 34653 Phone 727.835.4166 Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org Lee County ATTN: Amanda Cruz SalusCare Inc. 2789 Ortiz Ave Fort Myers, FL 33905 Direct Dial: 239-791-1548 Fax: 239-791-0111 E-mail: HYPERLINK "mailto:ACruz@SalusCareFlorida.org" ACruz@SalusCareFlorida.org Pinellas County: ATTN: Allison Hall Directions for Living 8823 - 115th Ave. North, Largo, FL 33773 Office: 727-434-0285 fax: (727) 547-4599 ahall@directionsforliving.org Sarasota & Desoto Counties: ATTN: Lindsay Jacobs Coastal Behavioral Health 1750 17th Street Sarasota, FL Office (941) 492-4300 ext. 136 Fax (941) 492-2170  HYPERLINK "mailto:ljacobs@coastalbh.org" ljacobs@coastalbh.org Polk, Hardee, Highland County ATTN: Jennifer Maul P.O. Box 1559 Bartow, FL 33831-1559 Office 863-519-0575, ext. 6245  HYPERLINK "mailto:jmaul@peacerivercenter.org" mailto:jmaul@peacerivercenter.org  The Vines (Female clients only as 1/2017) (Marion County) Contact: Lindsay King or Natasha Sanford Email:  HYPERLINK "mailto:Lindsay.King@uhsinc.com" Lindsay.King@uhsinc.com or  HYPERLINK "mailto:Natasha.Sanford@uhsinc.com" Natasha.Sanford@uhsinc.com 3130 SW 27th Avenue Ocala, FL 34474 352-671-3130 Females ages 13-17 only Florida Palms Academy (Broward County) Contact: Michelle Thomas or Yadavhi Singh Email:  HYPERLINK "mailto:mthomas@floridapalmsacademy.com" mthomas@floridapalmsacademy.com or  HYPERLINK "mailto:ysingh@floridapalmsacademy.com" ysingh@floridapalmsacademy.com 5925 McKinley Street Hollywood, FL 33027 954-963-0992 Trauma Resolution Focused Treatment Accepts kids up to 14 years old Daniel Memorial (Duval County) Erica Machnic Email:  HYPERLINK "mailto:emachnic@danielkids.org" emachnic@danielkids.org 3725 Belfort Road Jacksonville, FL 32216 904-296-1055 Sexual Reactive Unit Citrus (Broward/CATS) (Broward County) Contact: Gisela Suarez or Dr. Michael Jochananov Email:  HYPERLINK "mailto:giselas@citrushealth.com" giselas@citrushealth.com or  HYPERLINK "mailto:Michaelj@citrushealth.com" Michaelj@citrushealth.com 8450 South Palm Drive Pembroke Pines, FL 33025 954-342-0355 Sexual reactive treatment program Ages 13 17 years old 1 Pregnant youth at a time Lakeview Center Inc. (Escambia County) Jack Layfield 805-469-3502/352-671-3130 Email:  HYPERLINK "mailto:jack.layfield@bhcpns.org" jack.layfield@bhcpns.org Meridian 1920 North J Street Pensacola, FL 32501 850-469-3502 352-671-3130 Alternative Family Care (GIRLS ONLY) (Broward County) Program Coordinator Yaneque Malcolm 954-599-6561 or 954-680-8462 or  HYPERLINK "mailto:ymalcolm@altgroupcare.com" ymalcolm@altgroupcare.com 20250 SW 50TH PLACE Fort Lauderdale, Florida 33332 Program Coordinator Yaneque Malcolm 954-825-1650 or 954-252-0227 or  HYPERLINK "mailto:ymalcolm@altgroupcare.com" ymalcolm@altgroupcare.com 5050 SW 163rd Avenue Fort Lauderdale, FL 33331 St Augustine Youth Services (Saint Johns County) Contact: Leslie Snyder (BOYS ONLY)  HYPERLINK "mailto:LeslieS@sayskids.org" LeslieS@sayskids.org St. Augustine Youth Services 201 Simone Way, St. Augustine, FL 32086 (904) 829-1770 Life Stream/Turning Point (GIRLS ONLY) (Lake County) Contact: Michele Walsh Email:  HYPERLINK "mailto:MWalsh@lsbc.net" MWalsh@lsbc.net 19812 East 5th Street Umatilla, FL 32784 352-771-8996 Childs Name: ____________________________ Medicaid ID: _____________________________ Date of Staffing: _________________________ Date of Waive: ___________________________  %)*+<AB $ xj\XQXQXJ h*CJOJQJ^JaJ&h+%{h+%{5>*CJOJQJ^JaJ h+%{5>*CJOJQJ^JaJhKBjhKBUmHnHuhgJjhgJUmHnHuhn jh)UmHnHujh2UmHnHuB% $5$7$8$9DH$a$gd4p$5$7$8$9DH$a$gd*CJOJQJ^JaJ $$5$7$8$9DH$Ifa$gd$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gd kWWC2$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gdm$$5$7$8$9DH$Ifa$gdkd$$Ifl}\*-&>& &3& t .644 lap(yt " # hTTTC$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gdkd$$Ifl;\*-f>f f3f t .644 lBap(yt# $ 3 4 5 6 hTTTC$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gdkdR$$Ifl;\*-&>& &3f t .644 lBap(yt6 7 M Z i j kWWWF$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gdkd$$Ifl;\*-&>& &3& t .644 lap(ytM Y Z h i j k      0 C D X j k m o p  лЬ}q}hTCJOJQJaJh4ph*XCJOJQJaJh4phMrP5CJOJQJaJh4ph5g5CJOJQJaJh4ph5gCJOJQJaJ(h4phMrP5B*CJOJQJaJph h MhMrPh_dhMrPOJQJh4phMrPCJOJQJaJh4phHuLCJOJQJaJ'j k l y hTTTC$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gdkd$$Ifl;\*-f>f f3f t .644 lBap(yt hTTTC$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gdkdP$$Ifl;\*-f>f f3f t .644 lBap(yt   kWWWWWWF$5$7$8$9DH$Ifgd_d$$5$7$8$9DH$Ifa$gdkd$$Ifl;\*-&>& &3& t .644 lap(yt   0 D X p  hTTTTTT$$5$7$8$9DH$Ifa$gdkd$$Ifl;\*-f>f f3f t .644 lBap(yt WCCC$$5$7$8$9DH$Ifa$gdkdN$$Ifl;\*-f>f f3f t .644 lBap(yt$5$7$8$9DH$Ifgd_d hTTT$$5$7$8$9DH$Ifa$gdkd$$Ifl;\*-f>f f3& t .644 lBap(yt         - . 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