Behavior Wizard Referral Form

Behavior Wizards

Referral Information Form
Name

First NameLast Name
DOB

MonthDayYear
Date
Gender:
Race:
SSN:
PMI#
Serving County:
Financial County:
Spoken Languages:
Interpreter Needed:
Legal Status / Representative:
CASE MANAGER:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
FAX Number:
Please enter a valid phone number.
Email
example@example.com
LEGAL REPRESENTATIVE:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
FAX Number:
Please enter a valid phone number.
Email
example@example.com
RESIDENCE:
Provider Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
FAX Number:
Please enter a valid phone number.
Email
example@example.com
Contact Person

First NameLast Name
DAY PROGRAM / SCHOOL:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
FAX Number:
Please enter a valid phone number.
Email
example@example.com
Contact Person

First NameLast Name
PRIMARY CORRESPONDENT/ FAMILY CONTACT:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
FAX Number:
Please enter a valid phone number.
Email
example@example.com
Fiscal Support Entity (CDCS only):
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
FAX Number:
Please enter a valid phone number.
Email
example@example.com
Contact Person

First NameLast Name
Diagnosis (Include DSM V Code):
Medications:
PLEASE EXPLAIN THE PRESENTING BEHAVIOR PROBLEM(S):
EXPECTED OUTCOME: (Case manager goals for services)
(Case manager goals for services)
ADDITIONAL COMMENTS / REQUESTS:
(Provide any additional information of use)
Services Requested: Behavior Wizards (as the license holder) must provide and submit a summary of the services as authorized by the county case manager. The summary shall be provided to the case manager within 30 days of service termination. Check which services the case manager is requesting. If none are specified, A–C will be provided.
1. Assessment to determine the precipitating factors contributing to the crisis, including recommendations for medical assessments as appropriate (document in medical records if medical assessment is necessary or not).
2. Development of a provider intervention plan in coordination with the service planning team.
3. Consultation and staff training to the provider(s) and/or caregiver(s) as necessary to assure successful implementation of the recipient specific intervention plan.
4. Development and implementation of a transition plan to aid the recipient in returning home if out-of-home crisis respite was provided.
5. Ongoing technical assistance to the caregiver or provider in the implementation of the intervention plan developed for the recipient.
6. Recommendations for revisions to the 24-hour plan of care for the consumer to prevent or minimize future crisis situations in order to increase the likelihood of maintaining the recipient in the community
Select Services Requested

A. Assessment to determine the precipitating...B. Development of a provider...C. Consultation and staff...D. Development and implementation...E. Ongoing technical assistance...F. Recommendations for revisions...
Person making the referral:

First NameLast Name
Relationship to the client:
Is the client at risk of losing the current placement?
How quickly is Behavior Wizards intervention needed?

Authorization of Initial Units

(The start date will be the date of initial meeting when arranged by Behavior Wizards staff – funding source and units approved needs to be completed by case manager prior to the Initial Meeting.)

Billing Code	Cost (Per Unit)	Unit Length	Waiver Type	Waiver Title
T2013	$191.25	60 Minutes	DD, CADI, BI	Specialist Services
Contracted Service	$191.25	60 Minutes	Private Pay CDCS	Behavior Consultation

From the grid above select requested billing code:
SERVICE AUTHORIZATION

WAIVER – Case manager must screen the client for waiver services and authorize behavior specialist services on the service agreement. Services are billed directly to MHCP using

behavior specialist code. Update the CSP to reflect the need for behavior specialist services.

ICF-MR-PROVIDER – Is responsible for payment and billed directly. Provider may obtain authorization for behavior specialist services through 186. Shared service contract must be initiated and signed.

SPECIAL SERVICES CONTRACT – This includes use of Family Support Grant or other non-waiver funding sources.
- Attach copies of the following documents:
- Coordinated Service Support Plan (CSSP)
- Consent for Release of Information
- Individual Abuse Prevention Plan (IAPP)
- Current Psychological Assessment
- Current Individualized Education Plan (if consumer is attending school).

Behavior Wizards

CASE MANAGER:

LEGAL REPRESENTATIVE:

RESIDENCE:

DAY PROGRAM / SCHOOL:

PRIMARY CORRESPONDENT/ FAMILY CONTACT:

Fiscal Support Entity (CDCS only):