Bridge to Care - ECM Program
Referral Form
Date of referral
-
Month
-
Day
Year
Date
Individual Being Referred
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
ZIP Code
Gender identity
Please Select
Male
Female
Nonbinary/Gender diverse
Transgender male
Transgender female
Other
Prefer not to say
Preferred pronouns
Please Select
he/him
she/her
they/them
Interpreter needed?
*
Yes
No
Preferred language
Medi-Cal Managed Care Plan (MCP)
*
Blue Shield Promise Health Plan
Molina Healthcare
Kaiser Permanente
Community Health Group
Other
Unknown
If other, please specifiy
Medi-Cal Benefits Identification Card (BIC) ID Number
This is a 14-character alphanumeric code located on the front of the BIC. This information is necessary to determine eligibility. If you do not have access to the BIC, you can obtain it by calling the local San Diego Medi-Cal office: (866) 262-9881.
Does the individual currently have a caregiver or guardian involved in their care?
Yes
No
Name of caregiver or guardian
First Name
Last Name
Relationship of caregiver or guardian to individual being referred
Phone number of caregiver or guardian (if different from above)
Please enter a valid phone number.
Format: (000) 000-0000.
Interpreter needed?
Yes
No
Preferred language
Referring Party Information
Name
*
First Name
Last Name
Relationship to individual being referred
*
Please Select
Medical Provider
Behavioral Health Provider
Community Support Provider
Self
Family Member
Other Representative
Organization
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Reason(s) for Referral:
Do any of the following eligibility criteria apply to the individual being referred? Check all that apply.
*
Serious mental health or substance use disorder needs
Homeless or at risk of homelessness
At risk for avoidable emergency department or hospital utilization
Adult at risk of institutionalization
Adult nursing facility resident
Child welfare involvement
Children or youth enrolled in CCS or Whole Child Model with additional needs
None of the above
Do any of the following additional eligibility criteria apply to the individual being referred? Check all that apply.
*
Known or suspected mental health or substance use disorder(s)
One or more chronic health conditions
Known risk factors (e.g., DV/IPV, tobacco use, substance use, etc.)
Unmet health related social needs (e.g., housing and/or food insecurity)
One or more visits to the emergency department or hospital (medical or behavioral health) within the last 6 months
Two or more missed medical appointments within the last 6 months
Needs support navigating health system or coordinating services
Need for preventative services
Positive ACEs screening
None of the above
Approximant number of emergency department visits within the last 6 months
Reason(s) for emergency department visit(s). Check all that apply.
Mental health
Substance use (intoxication, withdrawal, or overdose)
Combination of mental health and substance use
Medical
Unknown
Approximant number of hospital admissions within the last 6 months
Reason(s) for hospital admissions(s). Check all that apply.
Mental health
Substance use (intoxication, withdrawal, or overdose)
Combination of mental health and substance use
Medical
Unknown
Additional comments
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