Referral

Client Name

Client DOB

Address

City

State

Zip

Phone

Alternate Phone

Parent/Guardian

Phone

Case Manager (if applicable)

Phone

School

Grade

Special Ed

Age

Race

Gender

Primary Care Provider

Phone

Probation Officer

Phone

Psychiatrist

Phone

Medication Name

Dosage

Frequency

Medicaid number

Medicaid Verified

MCO

MCO ID#

Diagnosis

Date of Last Psychiatric Hospitalization

Name of Facility

Documentation of Serious Mental Illness Status/ Presenting Needs: (check all that apply)

1. Has a major mental health disorder diagnosable under DSM V (or acceptable under DSM IV standards, as needed)

2. Has a severe, recurrent disability resulting from mental illness, with at least two of the following:

Unemployed, employed in a shelter setting, or supportive work situation; has markedly limited or reduced employment skills; or, has a poor employment history. Exhibits inappropriate behaviors which result in intervention by the mental health and/or judicial system. Has difficulty in establishing or maintaining a personal social support system. Requires public financial assistance for out-of-hospital maintenance, and may be unable to procure such assistance without help. Requires assistance with basic living skills such as hygiene, food preparation or money management.

3. Has a need for intensive mental health supportive services for and extended duration and/or with at least one of the following:

The client has experienced an episode of continuous supportive service residential care, other than hospitalization for a period of time long enough to have significantly disrupted the normal living situation.

Additional Need

Preliminary Plan for Service

Name of Screening Staff

Date

Services requested

Any others, please explain

Referral Source

Agency

Phone

Ext

Quick Links

Contact Info

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