Crisis Diversion Referral Form
Instructions: This form will be used by both the Crisis Diversion clinician and referring clinician to internally transfer clients in need of crisis diversion services. Please complete each section. If you are a referring clinician, check NA for any section addressed to the crisis diversion clinician. Once a referral has been submitted for Crisis Diversion Services, the file will be transferred to the crisis diversion therapist If you are the Crisis Diversion Therapist, please fill out all sections with Astrid *.
Clinician Name
*
First Name
Last Name
Clinician Email
example@example.com
License Type
*
Please Select
Master's Intern (Level 1)
LG/LC/LMFT/LMSW (Level 2-non supervisor)
Level 3 Supervisor (Level 3)
Medication Management NP
Crisis Diversion Therapist
Your Supervisor (If Applicable)
Please Select
Aisha Meertins, M.S., LCSW-C
Tiffany Royster, M.A., LCPC, LCMFT
Dr. Halima Dargan, PhD., LCPC
Keiryan Bolling, M.S., LCSW-C
Shay Williams, M.S., LCPC
Marie Hartfield, M.S., LCMFT
Maya D. Foster, M.S., LCMFT
Alicia Medina, NP (Meds Management)
What is the primary reason for the referral/request to the Crisis Diversion Therapist?
*
To support the patient with managing an emerging crisis outside of the scope of the current treatment plant
To provide short-term triaging to replace the patient's current treatment due to providers inability to meet the patient's current needs and frequency of treatment
Patient needs a detailed plan and active support with obtaining community resources and does NOT qualify for Psychiatric Rehabilitation Services
Pt was recently discharged from urgent/hospital care and needs stabilization
To obtain linkage to community resources via a full crisis assessment
Pt requires short-term counseling support due to high acuity medication management needs.
Patients needs an evaluation for school, work, disability, or other extensive paperwork
*N/A (I am the Crisis Diversion Therapist Transferring out the PT)
Other
Please check the most appropriate box
Crisis Diversion services will replace the current treatment services
Crisis Diversion Services will run concurrently with current treatment services
Other
Patient Details:
Patient Name:
*
First Name
Last Name
Clinical Assessment:
Presenting Problem: (Briefly describe the client's current situation, challenges, successes, or insights gained during your interactions with the client)
*
Self-Harm Behaviors:
Yes
No
Suicidal Ideation:
Yes
No
Please describe any other Risk Factors
Motivation for Treatment
Low
1
2
3
4
High
5
1 is Low, 5 is High
If you are Transferring PT to Crisis Diversion Therapist, Ensure the following is completed first.
*
Yes, I have reviewed this case with my Level 3 supervisor.
Yes, I have provided the client with appropriate resources (e.g., crisis hotline, support groups, community resources
*N/A (I am the Crisis Diversion Therapist Transferring out the PT)
Other
**Crisis Diversion Therapist Only** Transfers From Crisis Diversion
Front Desk can transfer pt back to referring provider
Front Desk can transfer pt back to medication management team
Front Desk can update records of pt being Discharged to an outside provider (e.g., IOP, PHP, Substance Abuse Program).
Front Desk can schedule PT with a clinician within the agency
Other
**Crisis Diversion Therapist Only** Checklist for Crisis Diversion Therapist
Discharge/Transfer Summary Completed on SP (must be completed for every pt leaving your care)
Chart Notes Added
Files attached to Pt's Simple Practice Chart (e.g. Assessments, DBT Skills Worksheets/Handouts, etc)
Clinician Signature
Submit
Should be Empty: