Mental Health Intensive Outpatient Services Referral
Client's Name:
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Do you have Medicaid?
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Please Select
YES
NO
Medicaid Number
The individual must meet all of the following criteria:
The individual must exhibit symptoms consistent with a DSM diagnosis (using the most current version of the DSM) that is documented in the initial assessment that requires and can reasonably be expected to respond to treatment interventions
Within the past 30 days, the individual has experienced persistent or increasing symptoms associated with their primary DSM disorder which has contributed to decreased functioning in their home, school, occupational or community settings that has led to negative consequences and difficulties maintaining supportive, sustaining relationships with identified family and peers due to a psychiatric disorder. Interventions at lower levels of care or in alternative, community-based rehabilitation services have been attempted but have been unsuccessful in adequately addressing the symptoms and supporting recovery for the individual to baseline levels of functional capacity;
The individual is at risk for admission to impatient hospitalization, residential treatment services, residential crisis stabilization or partial hospitalization as evidenced by acute intensification of symptoms, but has not exhibited evidence of immediate danger to self or others and does not require 24-hour treatment or medical supervision; or the individual is stepping down from inpatient hospitalization, residential crisis stabilization, or partial hospitalization program and is no longer exhibiting evidence of immediate danger to self or others and does not require 24-hour treatment or medical supervision;
The individual has a community-based network of natural supports who are able to ensure individual's safety outside the treatment program hours and a safety plan has been established;
The individual requires access to an intensive structured treatment program with an onsite multidisciplinary team;
The individual can reliably attend, and actively participate in, all phases of the treatment program;
The individual has demonstrated willingness to recover in the structure of an ambulatory treatment program; and
For youth, there is a family/caregiver resource that is available to engage with treatment providers and support and reinforce the tenets of the MH-IOP services.
Diagnosis/Presenting Issues
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Name of Medication(s)
Referring Person/Agency
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Referral Source Contact Number
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Please enter a valid phone number.
Signature:
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Today's Date
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Month
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Day
Year
Date
Submit
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