Do you have Medicaid? Yes / No (circle)

Individuals must meet all of the following criteria:

1. The individual has experienced a recent behavioral health crisis (within 72 hours of admission) or the individual is  transitioning from  or at risk of a higher level of care and requires short-term support with identifying and engaging in the services necessary to maintain safety and stability in the community;
2. Documentation  indicates evidence that the individual meets criteria for a primary diagnosis consistent with the most  recent version of the Diagnostic and Statistical Manual;
3. There is evidence from the individual or collateral contact indicating at least one of the following is present:
   1. High potential for crisis-cycling without this support;
   2. Individual does not have the ability and/or the resources to support maintenance of safety and/or stability in  the community until longer term services are available/ accessible;
   3. Individual has been engaged in alternative crisis service or treatment and no longer meets criteria for those services but continues to require community stabilization support;
4. The individual currently has moderate to high intensity behavioral and/or emotional needs and without intervention, will further interfere with their ability to function in at least one life domain: family, living situation, school, social work or community.