Adult
ALLEGANY COUNTY MENTAL HEALTH CASE MANAGEMENT PROGRAM
Adult Initial Referral and Intake Form
Participant: ______Phone#: ______DOB:______
Address: ______
SS#:______Sex: ___ Marital Status: ___
Referral Date: ______Referring Agency: ______
Contact Person: ______Contact#: ______
Reason for Referral: ______
______
Medicaid #: ______
If client does not have Medicaid they must meet the following criteria:
_____ Currently being discharged from an inpatient psychiatric facility or
____ To prevent eminent hospitalization
And
In addition to previous uninsured criteria clients must meet the following conditions:
____ Must have an income of no more than 200% of the federal poverty level
____ Must have an urgent need
Diagnosis:
Axis I To be eligible for services clients must fit into one of the following diagnostic
categories, please specify the diagnostic code for as many areas as apply:
Schizophrenia (295.00-295.99)______
Mood Disorder(296.00-296.89)______
Other Psychotic disorder(297.00-298.90)______
Borderline and Schizotypal personality disorders(301.83,301.20-301.22)______
Axis II ______
Axis III ______
Axis IV ______
Axis V ______
Provider Making Diagnosis ______Date of Diagnosis ______
One of the following criteria must be met for services:
____ Are in , are at risk of, or need continued community treatment to prevent inpatient psychiatric
Treatment;
____ At risk of, or need continued community treatment to prevent being homeless; or
____ At risk of incarceration or will be released from a detention center or prison.
The specific diagnostic criteria may be waived for the following two conditions:
____ An individual committed as not criminally responsible who is conditionally released from a
Mental Hygiene Administration facility; or
____ An individual in a Mental Hygiene Administration facility or a Mental Hygiene Administration
Funded inpatient psychiatric hospital who required community services. This excludes individuals eligible for Developmental Disabilities Administration’s residential services.
One of the following criteria must be met for services:
____ Not linked to mental health and medical services;
____ Lacks basic supports for shelter, food, and income;
____ Transitioning from one level of care to another level of care; or
____ Needs to maintain community-based treatment and services.
One of the following criteria must be met for General Services:
____ Has been discharged from a state mental hospital in the past 90 days.
____ Has been discharged from a mental health residential treatment facility within the last 12 months.
____ Has had more than one admission to a crisis stabilization unit(CSU), short-term residential facility(SRT), inpatient psychiatric unit, or any combination of these facilities within the last 12 months;
____ Is experiencing long-term and/or increasing acute episodes of mental impairment that may put him or her at risk of requiring intensive level of services.
One of the following criteria must be met for Intensive Services (Medicaid clients only):
____ Has been discharged from a state mental hospital in the past 30 days.
____ Has demonstrated a need for increased services from the General Level.
____ Has resided in a state mental hospital for at least 2 months in the past 24 months:
____ Resides in the community and has had two or more admissions to a psychiatric hospital in the past 12 months;
____ Resides in the community and has had five or more admissions to a crisis stabilization unit(CSU), short-term residential facility(SRT), inpatient psychiatric unit, or any combination of these facilities within the past 12 months;
____ Resides in the community and, and due to a serious mental illness, exhibits behaviors or symptoms that could result in long-term hospitalization if intensive interventions for an extended period of time or not provided.
____ Has resided in a state mental hospital for at least 6 months in the past 24 months.
Primary Care Provider: Tri-State CHC Other ______
In addition to the information above, Consumer has the following urgent needs:
____ Medication Assistance ____ Mental Health Linkages ____ Homeless/At Risk
____ Emergency Shelter ____ Missed MH Appts _____ Food ____ Application for MA/PAC
____ Application for Other Entitlements ____ Dual Diagnosis Tx ____ Somatic Care (describe below)
____ Being Discharged from hospital _____ Other: ______
Additional Comments: (Please provide as much information as possible)
______
Case Management Program Only:
Based on the above information, ______, has been determined eligible for Case Management Services, ____Yes ____No
Revised: Nov. 2009 Page 1 of 3 pages