CORE Referral Form

Email: coreintake@jemcare.org

Phone: 929-259-8227
Community Oriented Recovery and Empowerment (CORE) Referral Form
DATE OF REFERRAL

MonthDayYear
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
Assigned Sex at Birth*
Is the applicant willing to disclose their gender identity?

YesNo
Preferred Gender*
Pronouns*
Medicaid CIN*
Insurance Provider*
Is the applicant enrolled in a HARP plan?*

YesNoUnsure
Preferred Language
If Others, please specify*
Phone*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
CONSENT AND CONFIDENTIALITY
Has consent been obtained from the applicant or Legally Authorized Representative for this referral?*

YesNo
Name of Legally Authorized Representative (If Applicable)

First NameLast Name
Phone
Email
Relationship to Member
Preferred Language
Is applicant in Foster Care or under Guardianship?*

YesNo
If YES, please specify:
Please note any confidentiality concerns or treatment preferences
Applicant Availability for Services (Please include Days and Times i.e. Monday 2pm-5pm)
REFERRAL SOURCE INFORMATION
How was this referral being made?
Name of Referrer*
Relationship to Applicant*
Phone*
Email*
example@example.com
Role/Job Title*
Organization/Agency*
Agency Address
Agency Phone*
Where did you hear about JEMCare?
HEALTH HOME CARE MANAGER INFORMATION
Name
Phone
Email
Agency Name
Agency Phone
REASONS FOR REFERRAL
Primary Concerns (Check all that apply)*

Behavioral IssuesTrauma ExposureEmotional DistressFamily ConflictSocial IsolationFamily ConflictHousing/Financial InstabilityWork-Related IssuesLegal IssueOther
Symptoms of Concern (Check all that apply)*

Depression:Developmental DelaysAnxiety:Hyperactivity/Attention DeficitsPhobiaImpulsive BehaviorDanger to SelfRunaway/ElopementSuicidal Ideation(s)Negative Peer InteractionsSelf-InjuryPhysical AggressionDanger to Other(s)Verbal AggressionTemper Tantrums/OutburstsProblematic Social BehaviorSleep DisturbanceSexually Inappropriate/AggressiveEating DisturbanceSexually InappropriateSubstance Use (Alcohol/Drugs)Other
Any known safety concerns?
Diagnosis If the applicant does not have a verifiable diagnosis, please write N/A. If the client does have a verifiable diagnosis, please attach documentation to confirm
SERVICES
Services being requested (check all that apply)

Community Psychiatric Supports and Treatment (CPST)Psychosocial Rehabilitation (PSR)Family Support and Training (FST)Empowerment Services – Peer Support
Has the applicant received any previous services?

YesNo
Service Provider*
Type of Service/s*
Date of Service/s*

MonthDayYear
Date
GOALS
What goals would the applicant like to accomplish?
Is there any additional information the applicant or referring party believes is important for our team to be aware of, including urgent concerns or risk alerts?
CURRENT SUPPORT SYSTEM
Is the applicant connected to a Primary Care Physician (PCP)?

YesNoUnsure
PCP Name*
Facility Name*
Facility Address
Phone*
Email
Is the applicant connected to a mental health provider?

YesNoUnsure
Name*
Facility Name*
Facility Address
Phone*
Email
Is the applicant currently receiving support from any other services or agencies?

YesNo
Agency Name*
Type of Support*
Contact Person*
Phone*
Additional Information
Upload any additional documents or supporting materials relevant to the referral

Cancelof
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Community Oriented Recovery and Empowerment (CORE) Referral Form

CONSENT AND CONFIDENTIALITY

REFERRAL SOURCE INFORMATION

HEALTH HOME CARE MANAGER INFORMATION

REASONS FOR REFERRAL

SERVICES

GOALS

CURRENT SUPPORT SYSTEM