NBHN IRTS Referral Form

IRTS Referral Form

Northstar Behavioral Health IRTS Program. 1174 Western Avenue, Fergus Falls, MN 56537 https://www.northstarbehavioralhealthmn.com/irts

All fields marked with * are required.

Thank you for your interest in Northstar Behavioral Health Network IRTS. Please refer carefully to the section titled "Referral Documentation Checklist" on Page 4 of this form, and provide us with the required items as soon as possible. This information is necessary in order for us to make a determination of medical necessity for IRTS placement. If you are referring from a hospital, please complete the referral form to the best of your ability including the name and contact number of the individuals case manager, and have the individual complete the "IRTS Client Agreement" form and sign a release form allowing communication with their case manager. If you have any further questions, please do not hesitate to contact us for addition information about the program, eligibility requirements, and anticipated bed openings.

Sincerely,

NBHN Team
IRTS Admission Criteria
An eligible IRTS member must meet the following:

Be 18 years old or older
Be eligible for MHCP
-Meet the IRTS admission criteria:
-Diagnosed with a mental illness
-Functional impairment because of mental illness, in three or more areas, utilizing the functional assessment
The Individual must meet one of the following criteria (select all that apply):*

A history of two or more inpatient hospitalizations in the past yearSignificant independent living instability or homelessnessFrequent use of mental health related services, yielding poor outcomesThe written opinion of a licensed professional that this type of treatment is needed. A lower level of care does not meet the individual’s needsLikely to experience a mental health crisis or require a more restrictive setting if no access to intensive services
All fields marked with * are required. All questions on this referral are required. If a field is not applicable to the client, please type "N/A".
Diagnosis**
Email of who is completing the form**
Individuals Name**
Preferred Name*
Date of Birth**

MonthDayYear
Date
Age**
SSN**
Legal Gender**
Gender Identity**
Phone Number*
Format: (000) 000-0000.
Home Address**
Current Location**
Anticipated Discharge from Current Location**
Preferred Date for IRTS Admission**

MonthDayYear
Date
County Social Worker:
Primary*
Secondary
Type pf Commitment: *

MIMI/CDCDMI&DN/A
Guardianship Legal Status**
Financial Worker:
Name
Phone
Format: (000) 000-0000.
Agency
Probation Officer:
Name
Phone
Format: (000) 000-0000.
Agency
Support Network:
Name
Phone
Format: (000) 000-0000.
Who and what services comprise the individuals current support network: *
Ex. Family member, Sponsor, Peer Specialist, ACT/ARMHS
Monthly Gross Income:
Reductions to Income (amount and reason):*
Current Housing*

OwnRentHomeless
List any periods of homelessness or living instability during the past 12 months*
What housing referrals are in place?*
Health Coverage:
Name of Plan**
Policy ID or PMI #**
Does plan cover IRTS placement?**

YesNo
If not how will IRTS be funded?*
Sources of Income: *

Employer (list name below)SSIGAWaiverSocial Security Pending (list date applied below)SSDI/RSDIGRHVeteran
If income comes from an employer please list:
SS Date Applied
Goals for Placement (please name 3 goals related to mental health or Substance Use Disorders)***
List Current and recent psychiatric hospitalization (during the past 12 months) Include the name of each hospital and approximate dates of length of admission: *
Explain why this person's functioning g indicates a need for 24 - hour intensive residential services. Include any goals the person can identify, and any discharge plans following completion of IRTS: *
Please indicate Date(s) and Brief Explanations of All That Apply:
Legal Issues*
Medication Noncompliance*
Suicidal Behavior/Self-Injurious Behaviors*
History of Abuse Trauma or Loss*
History of Physical, Verbal, or Sexual Aggression*
History of Property Destruction*
History of Fire Setting*
Intellectual Functioning*
Mobility Considerations*
Eating Disorders or Eating Concerns*
Complex Physical Health Concerns*
Co-Occurring Medical Conditions:*
Known Allergies:*
Discharge plans after IRTS placement:*
The following information will be required before intake in addition to the items listed on the "Referral Documentation Checklist" below:*

1 month supply of medications and original scripts for all medicationsSigned physician orders for all medication and insurance information faxed or called in to the appropriate PharmacyDischarge Summary if the person is coming from another facility
Northstar Behavioral Health IRTS Referral Documentation Checklist:
Thank you for showing interest in our Intensive Residential Treatment Program. To expedite the referral process, the following documentation must be included with the referral packet. Please check all that is included:*

Diagnostic AssessmentCurrent Functional Assessment documenting at least 3 areas of functional impairmentMost recent Rule 25 or SUDS comprehensive evaluation and recommendations (if applicable)List of current medications, including dosages & administration times
AND if the client is currently in the hospital, please include the following information:

Psychiatric AssessmentSocial Work AssessmentHistory and PhysicalCurrent medication list signed by the prescribing physician or nurse practitioner
If the client is on a civil commitment or stay of commitment, please include the pertinent LEGAL DOCUMENTS:

Pre-Petition Screening reportFinal Commitment OrdersJARVIS OrdersCommitment Case Manager Info
In the spaces below, please upload all documentation listed above. If Authorizations for Release of Information are available, please include those as well.

Cancelof
Mental Health Professional Information:
MHP Name*
Date*

MonthDayYear
Date
Direct contact phone number:*
Email
example@example.com
If any of the above documentation is not included, please explain:
If additional documentation available that cannot be uploaded, please FAX to ADMISSIONS at 651-488-0887.
I accept that this is the legal representation of my signature
Health Intake:
Individual's Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
DRUG ALLERGIES/DESCRIBE REACTION:*
Current physical examination/medical history is enclosed?*

YesNo
The individual is currently free from communicable diseases*

YesNo
If no, please explain
Nursing services are provided a minimum of 8 hours per week to the facility. This individual is appropriate for placement in a facility providing 24-hour supervision and direction by non-nursing personnel*

YesNo
Current medication list is enclosed/attached. *MEDICATION LIST MUST BE SIGNED BY PHYSICIAN*

YesNo
Individuals must arrive with a 30-day supply of medications. A 30-day supply of medications has been sent to: THRIFTY WHITE PHARMACY 1484 W. Lincoln Ave. Fergus Falls, MN 56537 (218)736-5565*

YesNo
Does this individual need any special dietary accommodations? If Yes, Please describe dietary needs.
Should be Empty:

County Social Worker:

Financial Worker:

Probation Officer:

Support Network:

Health Coverage:

Mental Health Professional Information:

Health Intake: