CCS Medication Management Referral

CCS Medication Management Referral

The Psychology Clinic
*REMINDER*

Please be sure that your client has been enrolled in CCS for at least 30 days and is engaged in other CCS services before submitting a medication management referral
Referral Date

MonthDayYear
Date
CCS Enrollment Date

MonthDayYear
Date
Client Name

First Name (Chosen Name in parentheses if different)Last Name
Age/DOB/Legal Sex
Pronouns + Gender Identity
Client Phone
Clients 18+ ONLY.Format: (000) 000-0000.
Client Email
Clients 18+ ONLY.
Legal Guardian(s) Name/Phone
If applicable
Caregiver(s) Name/Phone
If applicable
Service Facilitator

NameAgency
SF Email/Phone

EmailPhone Number
Reason for referral:
Is the client interested in/willing to take medication?
Is there a specific provider your client would like to work with?
**Selecting a provider does not guarantee placement with that provider**
Mental Health/Psychiatric and Substance Use diagnoses
Current Medication Prescribers (Name/Health System/Location)
What medications is the client taking? Include all medications (psychiatric, substance use AND medical).
Current CCS Services:
Is client engaged with CCS Services?
What are the barriers to engagement?
Settlement Agreement?
Date of Settlement Expiration

MonthDayYear
Date
History of NSSI or Suicide Attempts?
Type, Method, est. dates?
Previous Psychiatric Treatment?

Other
Current and Previous Substance Use Disorders

Other
Current Substance Use

Other
History of Overdose?
Substance and Date(s) of OD:
Other substance use information:
Additional information (sobriety, length of use, previous treatment...)
Medical History

Other
Is there anything else you would like us to know?
Should be Empty:

CCS Medication Management Referral

*REMINDER*

REMINDER