Estelle’s Personal Care Services Intensive In-home Referral

Estelle’s Personal Care Services Intensive In-home Referral For
Today’s Date

Month Day Year
Date
Referral Source
Referring Agency
Referral Source Phone
Reason for Referral
Client Name
Gender
Client Address
Client Phone
DOB
Age
Do you have Medicaid?

Yes No
Medicaid Number
Social Security #
Monthly Income
Individuals qualifying for this service shall demonstrate a clinical necessity for the service arising from mental, behavioral or emotional illness which results in significant functional impairments in major life activities. The diagnosis must be the primary clinical issue addressed by services and must support the mental, behavioral or emotional illness attributed to the recent significant functional impairments in major life activities.
Diagnosis/Presenting Issues
Does the individual meet at least two of the following criteria at the time of referral to the service:
Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community.

Yes No
Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services, or judicial system are or have been necessary resulting in being at risk for out of home placement.

Yes No
Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior resulting in being at risk for out of home placement.

Yes No
Are you currently receiving any type of supports?
Agency
Are you a returning/past client?
Do you have specialized ambulation needs?
Are you currently hospitalized?
Location
Discharge Date

Month Day Year
Date
Do you receive case management from the CSB?
Case Manager Name
Case Manger Contact Number
Please fax referral form to 757-299-1921 You can reach us at 757-620-1008 with any questions
Office Staff Only
Was the referral accepted?
If declined, where was s/he referred?
Reason declined?
Intake Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Estelle’s Personal Care Services Intensive In-home Referral For

Office Staff Only