Effective Date
Instructions
11/2025
Purpose
Form 1016 is used to guide the discussion of Preadmission Screening and Resident Review (PASRR) mental illness (MI) specialized services the Local Mental Health Authority (LMHA) or Local Behavioral Health Authority (LBHA) can provide to MI positive PASRR residents.
When to Prepare
The LMHAs and LBHAs can use Form 1016 at the initial and annual Interdisciplinary Team meetings as well as any MI specialized service team meeting where PASRR MI specialized services are discussed.
Detailed Instructions
Name – Enter the person’s first and last name.
PE DLN – Enter the PASRR Evaluation document locator number.
Date – Enter the date the form is completed.
Section 1 – Specialized Services Recommended by the PE
Check each recommended MI specialized service identified on the PASRR evaluation, if applicable.
Section 2 – PASRR MI Specialized Services Discussion
For each PASRR MI specialized service, the LMHA or LBHA representative will discuss if the person does or does not want the specified specialized service. If the person refuses any service, the LMHA or LBHA representative must provide a detailed explanation of the reason for refusal and efforts to resolve barriers identified.
Section 3 – LMHA or LBHA Signature
LMHA or LBHA Printed Name – Enter or print the name of the LMHA or LBHA representative.
LMHA or LBHA Signature – The LMHA or LBHA representative signs the form.
Service Definitions
Service definitions are listed as described in the Texas Resilience and Recovery Utilization Management (UM) Guidelines (PDF).