Children's Health Home Referral Form

Email: intake@jemcare.org

Phone: (718) 506-0721
Children's Health Home Referral Form
INSTRUCTIONS: This form must be completed in its entirety to allow JEMCare to verify eligibility for services.
Member's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Medicaid ID*
Insurance Name (if any)
Preferred Language
If Other, please specify
Phone Number*
Format: (000) 000-0000.
Email
Emergency Contact Number
Address*
City*
State
Zipcode*
CONSENT AND CONFIDENTIALITY
Date Permission to Refer was obtained*

MonthDayYear
Indicate the Individual from whom consent to refer was obtained*

ParentGuardianMember/ self/ individual if 18 years or olderMember/ self/ individual under 18, but is a parent, pregnant, or marriedLegally authorized representative
Parent/ Guardian/ Legally Authorized Representative' Name*

First NameLast Name
Address
Relationship to Member*
Phone*
Format: (000) 000-0000.
Is Member in Foster Care?*

YesNoUnknown
Is Member’s Parent/Guardian Currently Enrolled in a Health Home?

YesNoUnknown
Referral Source Information
Referral Type*
Name of Referrer*
Name of Referral Organization
Phone*
Format: (000) 000-0000.
Email
REASON FOR REFERRAL
Diagnosis (Check all that apply)*

AsthmaAutismADHDObesitySerious Emotional Disturbance (SED)HIVComplex TraumaSickle Cell AnemiaOther
Appropriateness/Risk Factor (Check all that apply)*

Experiencing an adverse event disability/inpatient/emergency department/psychiatric hospital/detox skilled nursing/crisis stabilization/mandated preventive services/out of home placement/deceased guardian) in the last 6 monthsDifficulty navigating system due to member’s (or guardian) physical or behavioral health condition such as activities of daily living, learning or cognition issues, transportation, scheduling medical appointmentDoes not have specialist to treat physical or behavioral condition or has not seen a provider (e.g., PCP, BH, etc.) in the last yearDiagnosed with serious physical or behavioral health condition or received initial Disability Determination (SSI or DOH Disability Certificate/letter) within the last 6 monthsNot adherent to or having difficulty managing treatment or certain medicationsNeeds assistance applying for/accessing benefits such as OPWDD, Childcare Support, SNAP, WIC, SSI, Cash Assistance, Housing Support. etc.Unable to access food due to financial limitations, inability to shop, dietary restrictions, etc.Currently homeless or has no stable living arrangementCurrently impacted by violence at home or by intimate partnerReleased from incarceration/detention center within the last 6 monthsRecent change in guardianship/caregiver or caregiver/guardian currently enrolled in HH
Additional Information/ History
Submission Date*

MonthDayYear
Date
Should be Empty:

Children's Health Home Referral Form

CONSENT AND CONFIDENTIALITY

Referral Source Information

REASON FOR REFERRAL