Mobile Mental Health Treatment (MMHT) Referral Form

Mobile Mental Health Treatment (MMHT) Referral Form
Blair, Bedford, Carbon Clearfield, Cambria, Jefferson Monroe, Pike & Somerset Counties
County
Date

MonthDayYear
Date
Referral Source Name
Type of Referral: Self Agency Physician Family/Friend, other
Phone
FacilityAgencyPhysician Making Referral
Referral Name with middle initial
Phone
DOB
Insurance
SSN
Address
Physician
Phone
Last Medical Exam
Psychiatrist
Last Psychiatric Evaluation
Last Psychiatric Evaluation
Diagnosis
Comments
History of Substance Abuse
Inpatient Psychiatric
DA Inpt
History of Incarceration or Parole?
Current Medications
Other AgenciesServices Client is Receiving
Does patient have a history of trauma?
If Yes Action Taken
Referred To (name agency/program)
Please check the criteria that applies to the person you are referring

Medical condition, as documented in the treatment plan, that impairs the ability of the individual to participate or precludes the individual from participating in psychiatric outpatient clinic services.
Medical Necessity Criteria for Mobile Mental Health Therapy

Psychiatric condition, as documented in the treatment plan, that impairs the ability of the individual to participate or precludes the individual from participating in psychiatric outpatient clinic services. One or more significant psychosocial stressors, as documented in the treatment plan, that impairs the ability of the individual to participate or precludes the individual from participating in psychiatric outpatient clinic services.

Individual must agree to participate in Mobile Mental Health Treatment, be 21 years of age or older, and have Medical Assistance.

Talked to Client (date):Called and left message (date/s): Called Physician for Order (date/s): No Primary Care Physician Client does not meet criteria for mobile therapy Referred to Another Agency/Service: Physician's order received: (date): Provider: Appointment Scheduled:
Talked to Client date

MonthDayYear
Date
Called Physician for Order dates

MonthDayYear
Date
Called and left message dates

MonthDayYear
Date
Physicians order received date

MonthDayYear
Date
Referred to Another AgencyService
Appointment Scheduled
Date of Physicians order

MonthDayYear
Date
Provider
Should be Empty: