PM Form 4.4.1

Consultation and Clinical Intervention

Program Referral`

Submit completed referral form along with required attachments to the CCI Admissions Team via secure email to . Use Subject Line: “CCI Referral”.

Member Name: / DOB: / //
CIS ID: / AHCCCS ID:
Referral Information
Referral Date: / Assigned ICCA: / ICCA Site:
//
Name of person making the referral: / Telephone number:
() -
Member Demographic Data
Member Phone Number: / () -
Member's current setting:
Independent Living / Residential / Family Home / Relative Placement
Other:
If hospitalized, name of hospital:
If Inpatient, Date of Current Admission: / //
Other Setting (specify):
Member's Physical Address:
Street Address / City / State / Zip
Member's Mailing Address:
Street Address / City / State / Zip
Guardian Information (if applicable) / Not applicable
Guardian's Name: / Relationship to Member:
Phone Numbers(s): / () - / () - / () -
Guardian's Mailing Address:
Street Address / City / State / Zip
Email Address:
Member Name: / DOB: / //
CIS ID: / AHCCCS ID:
DDD Contact Information
DDD Contact's Name: / Position:
Phone Numbers(s): / () - / () - / () -
Local DDD Office Address:
Street Address / City / State / Zip
Email Address:
Other Agency Involvement (if applicable)
Agency Name: / Contact Person:
Phone Number: / () - / Fax Number: / () -
Email Address:
Agency Address:
Street Address / City / State / Zip
Medical Health Plan
AHCCCS Health Plan: / AHCCCS ID #:
Medicare A or B :eligible? / Yes / No / If yes, Medicare D enrolled? / Yes / No
ALTCS / Yes / No
Current Diagnoses
Axis I:
Axis II:
Axis III: / Axis IV: / Axis V:
Primary Diagnosis (Must be mental disorder as defined by ARS):
Previous Diagnoses:
Substance Abuse History
Does the member have a history of substance abuse? / Yes / No
If yes, provide details:
Member Name: / DOB: / //
CIS ID: / AHCCCS ID:
Reason for Referral (include behavioral, medical and developmental needs which have presented significant challenges for serving the member successfully in the community):
Interventions Already Attempted (include all interventions the CSP has implemented to attempt to modify the behavior and describe results):
Anticipated Outcomes of Program Involvement (describe the changes expected in member behavior and lifestyle improvements):

Required Attachments: Intake Care Coordination Agency (ICCA):

Psychiatric Evaluation (most recent) / Current Behavioral Health Service Plan
Current Crisis and Safety Plan / Functional Behavior Assessment (if applicable)
List of all services, with dates (12 mos) / Current DDD ISP

Documents that may be requested at a later date (if applicable):

Behavior Support Plan / Psycho-educational Assessment
Court Ordered Treatment Documents / Guardianship information
Competency Evaluations / Probation/Parole/Mental Health Court Orders

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Effective Date: 10/01/2015