OCAPICA Wellnessessity - Referral Form

Referring Person/Title:

Agency/Dept:

Email

example@example.com

Phone Number

Please enter a valid phone number.

Fax

Please enter a valid phone number.

Date

Submission Date

Date

You are completing this form as:

Well(ness)sity ECM staff memberWell(ness)sity PEARLS staff memberClient / Family member / Community partner

Name

Gender

Sex

Address

Phone Number*

Please enter a valid phone number.

DOB*

Date

Age

School (if applicable)

Ethnicity

Language

Do you have health insurance?

YesNo

Insurance Name

Insurance Number

Name

Relationship

Address

Phone Number

Please enter a valid phone number.

Language:

I am looking for (select all that apply)

Enhanced Care Management/Community Health WorkerPEARLS Services

Do any of these apply to you?

Experiencing or At Risk of HomelessnessAt Risk of Frequent ER or Hospital VisitsMental Health or Substance Use Support NeedsAt Risk of Needing Long-Term CarePregnant or Postpartum Adults (Birth Equity)Children and Youth with Complex Medical Needs (CCS / Whole Child Model)Families Involved with Child Welfare Services

Do you need a bilingual worker?

YesNo

If yes, specify language:

Do you need any other accommodations?

YesNo

If yes, please specify:

Do OCAPICA staff need to talk with referring person prior to intake?

YesNo

Has Participant been notified that an OCAPICA staff will contact them?

YesNo

OK to leave voice message?*

YesNo

OK to leave text message?*

YesNo

Please write availability for introductory call appointment:

The referring party has explained to me the purpose for this referral and I agree to have a copy of this referral faxed or to take a copy of the referral to OCAPICA. I agreee to attend any scheduled appointments with the Program.

I authorize the release of information between {agencydept} {referringPersontitle} (referring agency) and OCAPICA for the period this service agreement remains in effect. This information will pertain to the reasons for referral and will be used for assessment and intake of the participant(s) to be served. This referral was explained to me in my primary language.

Participant Signature

Date

Referring Person Signature

Date

Wellnessessity staff: please enter the password to access page 2.
Non-staff: you can skip now.

Passcode

Client is an Adult or a Child/Youth?

AdultChild/Youth

Which POF best fits client?

Adults Experiencing HomelessAdults at Risk for Avoidable Hospital or ED UtilizationAdults with Serious Mental Healthand/or Substance Use Disorder (SUD) NeedsAdults living in thecommunity who are at risk for LTC InstitutionalizationPregnant and Postpartum Individuals at Risk for Adverse Perinatal Outcomes

Homelessness: Adults Experiencing Homeless

Member is experiencing homelessness ANDMember has at least 1 complex physical, behavioral or developmental health need(includes pregnancy or post-partum, 12 months from delivery), for which the Member would benefit from care coordination.

Adults at Risk for Avoidable Hospital or ED Utilization

Over the last 6 months, the Member has had 5 or more emergency room visits that could have been avoided with appropriate care; AND/OROver the last 6 months, the Member has 3 or more unplanned hospital and/or short-term skilled nursing facility stays that could have been avoided with appropriate care;

Adults with Serious Mental Healthand/or Substance Use Disorder (SUD) Needs

Specialty Mental Health Services (SMHS) delivered by MHPs: Significant impairment(distress, disability, or dysfunction in social, occupational, or other important activities)OR A reasonable probability of significant deterioration in an important area of life functioning. ORDrug Medi-Cal Organization Delivery System (DMC-ODS): Have at least 1 diagnosis for Substance-Related and Addictive Disorder with the exception of Tobacco-related disorders and non-substance-related disorders. ORDrug Medi-Cal (DMC) Program: Have at least 1 diagnosis for Substance-Related and Addictive Disorder with the exception of Tobacco-related disorders and nonsubstance-related disorders. ANDMember is actively experiencing at least 1 complex social factor influencing their health, which may include, but is not limited to: lack of access to food; lack of access to stable housing; inability to work or engage in the community; former foster youth; or history of recent contacts with law enforcement related to mental health or substance use symptoms; ANDHigh risk for institutionalization, overdose, and/or suicide; ORUse crisis services, ERs, Urgent Care or inpatient stays as the primary source of care; OR2+ ER visits or 2+ hospitalizations due to Serious Mental Illness or SUD in the past 12months; ORPregnant or post-partum (up to 12 months from delivery)

Adults living in the community who are at risk for LTC Institutionalization

Living in the community and meets Skilled Nursing Facility (SNF) Level of Care criteria; ORRequires lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illness/injury; ANDMember is actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to: Needing assistance with activities of daily living, communication difficulties, access to food, access to stable housing, living alone, the need for conservatorship or guided decision-making, poor or inadequate caregiving which may appear as a lack of safety monitoring); ANDMember is able to reside continuously in the community with wraparound supports.

Pregnant and Postpartum Individuals at Risk for AdversePerinatal Outcomes

Member is pregnant or postpartum (through 12 months period); ANDMember is subject to racial and ethnic disparities as defined by California public healthdata on maternal morbidity and mortality. As of 2024, Black, American Indian or AlaskaNative, and Pacific Islander Members are included in this definition (referring individualsshould prioritize Member self-identification).

Which POF best fits client?

Homeless Families or Unaccompanied Children/YouthExperiencing HomelessnessChildren and Youth At Risk for Avoidable Hospital or ED UtilizationChildren and Youth with Serious Mental Health and/or SUD NeedsChildren/Youth Enrolled in California Children’s Services (CCS)or CCS WCM with Additional Needs Beyond the CCS ConditionChildren/Youth Involved in Child Welfare

Homeless Families or Unaccompanied Children/YouthExperiencing Homelessness

Child/youth or family with Members under 21 years of age, who are experiencinghomelessness (unhoused, in a shelter, losing housing in next 30 days, exiting aninstitution to homelessness, or fleeing interpersonal violence); AND/ORChild/youth or family is sharing the housing of other persons (i.e., couch surfing) due toloss of housing, economic hardship, or a similar reason; or is living in a motel, hotel,trailer park, or camping ground due to the lack of alternative adequateaccommodations; is living in emergency or transitional shelter; or is abandoned inhospital (in hospital without a safe place to be discharged to)

Children and Youth At Risk for Avoidable Hospital or ED Utilization

Child/youth has 3 or more emergency room visits that could have been avoided with appropriate care within the last 12 months; AND/ORChild/youth has 2 or more unplanned hospital and/or short-term skilled nursing facility staysthat could have been avoided with appropriate care, within the last 12 months.

Children andYouth with Serious Mental Health and/or SUD Needs

Specialty Mental Health Services (SMHS) delivered by MHPs: Members under age 21 qualify to receive all medically necessary SMHS services; ORDrug Medi-Cal Organization Delivery System (DMH-ODS): Members under age 21 qualify to receive all medically necessary DMC-ODS services; ORDrug Medi-Cal (DMC) Program: Covered services provided under DMC shall include all medically necessary SUD services for individuals under 21 years of age; OR

Children/Youth Enrolled in California Children’s Services (CCS) or CCS WCM with Additional Needs Beyond the CCS Condition

Member is enrolled in CCS or CCS WCM; ANDMember is experiencing at least 1 complex social factor influencing their health. Examples include (but are not limited to) lack of access to food; lack of access to stable housing; difficulty accessing transportation; high measure (four or more) of ACEs screening; history of recent contacts with law enforcement; or crisis intervention services related to mental health, former foster youth, and/or substance use symptoms

Children/Youth Involved in Child Welfare

Member is under age 21 and is currently receiving foster care in California; AND/ORMember is under age 21 and previously received foster care in California or anotherstate within the last 12 months; AND/ORMember is under age 26 and aged out of foster care (having been in foster care on their18th birthday or later) in California or another state; AND/ORMember is under age 18 and is eligible for and/or in California’s AdoptionAssistance Program; AND/ORMember is under age 18 and is currently receiving or has received services fromCalifornia’s Family Maintenance program within the last 12 months.

Referral Form

PARTICIPANT INFORMATION

PARENT/CAREGIVER OR EMERGENCY CONTACT INFORMATION

REASONS FOR REFERRAL

SERVICE AGREEMENT AND AUTHORIZATION TO RELEASE INFORMATION

For Well(ness)essity Staff Only

Adult (Age 21 or Older)

Child/Youth (Under 21)