Referral Form - Mental Health Skills-Building
Referral Caseworker Name:
First Name
Last Name
Date of Request:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Agency or Company Name:
Agency/Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency/Company Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Caseworker Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Client Name:
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Race:
Client Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian/Parent Name:
Guardian/Parent Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Funding Source:
CSA
Medicaid
Other
Please explain other funding source:
Primary Reason for Referral:
Identified Needs/Areas of Concern:
Psychiatric Symptoms Management
Psychiatric/Physical Illness
Medication Management
Appointment Compliance
Community Resources
Social Skills/Relational Skills
Safety/Risk of Injury
Substance Abuse
Personal Hygiene
Household Chores
Residential/Housing
Nutrition/Food Availability
Money Management
Structured Daily Activities
Occupational Issues
Anger Management
Legal Issues
School Issues/Behavior
Social Isolation
Family/Parental Conflicts
Cognitive/Learning Deficits
Traumatic Event(s)
Diagnoses:
Medical Disorders:
Medications:
Current or Past Substance(s) Abuse (please describe).
Caseworker Signature:
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PLEASE CONTINUE TO NEXT PAGE TO FILL OUT ELIGIBILITY INFORMATION
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Medicaid Eligibility For Mental Health Skills-Building
(Individual needs all A-E criteria to qualify)
A. The individual shall be in an independent living situation or actively transitioning into an independent living situation within the following 6 months (please check to indicate meets criteria):
Meets criteria
The individual shall have one of the following as a primary Axis I DSM diagnosis:
Schizophrenia or other psychotic disorder as set out in the DSM; OR
Major Depressive Disorder - Recurrent; OR
Bipolar I; OR Bipolar II/ OR
Any other Axis I mental health disorder documented by physician within the past year( see listed below):
To include the following:
That is a serious mental illness or serious emotional illness;
That results in severe and recurrent disability
That produces functional limitations in the individual's major life activities;
That requires individualized training in order to achieve or maintain independent living in the community
The individual shall require individualized training in acquiring basic living skills: (check appropriate needs only)
Symptom management;
Adherence to psychiatric and medication treatment plans;
Development and appropriate use of social skills and personal support system;
Personal hygiene
Food preparation;
Money management;
Other
The individual shall have a prior history of any of the following with supportive documentation: (only one shall be met for initial service only)
Psychiatric hospitalization;
Residential crisis stabilization;
Placement in a psychiatric residential treatment facility (RTC Level C);
TDO evaluation as a result of decompensation related to serious mental illness;
Intensive Community Treatment (ITC);
Program of Assertive Community Treatment (PACT) Services
E. The individual shall have had a prescription for an antipsychotic, mood stabilizer, or antidepressant medication within the last 12 months. (Please check below to indicate meets criteria).
Meets criteria
Signature of Caseworker:
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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