Referral Information
Onondaga County
SPOA - ADULT
Page 1 of 6
~ SPOA Point of Access Application ~ 2015.4 ~
For Adults with SPMI
Send with a recent PSYCHOSOCIAL, ASSESSMENT, or mental status exam, and/or progress notes and the signed SPOA Permission Form.
1 - REFERRAL INFORMATIONReferral is for: / □ Non Medicaid Care Management □ ACT Team □ Residential Services
□ Independent Supported Housing Program □ Forensic CM □ Other: ______
Date of Referral: / Applicant Gender: / □ Male □ Female
Applicant Name:
Applicant last 4 SSN: / Applicant DOB:
Home Street Address:
(City, State, Zip)
Applicant Phone Number: / Applicant Cell Number:
Applicant Email Address:
Current location:
Veteran or served in military? □ Yes □ No Branch/ type of discharge: ______
Service Connected Disability? □ Yes □ No If Service Connected ______%
Alternate Contact, Address and/or Phone # for Client:
May we leave a message? □ Yes □ No / Emergency Contact Name, Address & Phone #:
Referring person contact information: □ Provider □ Non-Provider
Name: ______
Agency: ______
Address: ______
Phone: ______Fax: ______
Email Address: ______
Primary Referral Organization Affiliation
Please select one of the following:
□ Self, Family, Friend / □ State Psychiatric Ctr (inpt) / □ Social Services
□ Mental Health Outpatient program / □ General Hospital ER / □ Family Court
□ Mental Health Residential Program / □ General Hospital (medical) / □ Criminal Court
□ CPEP or Mobile Crisis / □ Health Care Provider / □ Probation/parole
□ Chemical Dependency Program / □ OPWDD Service / □ Jail/Prison
□ Health Home Care Management / □ Shelter for the homeless / □ Other:
2 - PERSONAL AND DEMOGRAPHIC INFORMATION
Race / Ethnicity / Primary Language / English Proficiency
(If primary language is not English)
□ White, Non-Hispanic
□ Black, Non-Hispanic
□ Hispanic
□ Asian
□ American Indian or Native
□ Other (specify) ______/ □ English
□ Spanish
□ American Sign Language
□ Other (specify)
______/ □ Does Not Speak English.
□ Poor
□ Fair
□ Good - Does Not Need Translator
Currently receive care management / care coordination?
□ No □ Yes / If Yes, Agency Name:
Current Marital Status / Custody Status of Children
□ Single, never married
□ Currently married
□ Cohabiting with significant other/domestic partner
□ Divorced/separated
□ Widowed / □ No children
□ Have children - all older than 18 years
□ Minor children currently in client’s custody
□ Minor children not in client’s custody but have access
□ Minor children not in client’s custody - no access
Living Situation at Time of Referral
□ Lives alone □ Assisted /supported living (specify)
□ Lives with spouse/partner □ Nursing home/medical setting (specify)
□ Lives with parents □ Supervised Apartment Program (specify)
□ Lives with other relatives □ Supervised group home (specify)
□ Homeless - streets/parks □ Psychiatric hospital /Inpt Rehab (specify)
□ Homeless shelter/emergency housing □ Correctional setting (specify)
□ Other:
Please List All Other Members of Your House Hold:
Current Educational Level / Current Employment Status
□ No formal education
□ Some grade school (1-8th grade)
□ Completed grade school
□ Some HS (9-12th grade, but no diploma)
□ HS diploma or GED
□ Vocational, business training
□ Some college, no degree
□ College degree
□ Masters degree
□ Other:______/ □ No employment
□ Full-time
□ Part-time
□ Sheltered workshop
□ Has job coach
□ Access-VR involvement
□ Jobs Plus
□ Jobs Plus Exempt
□ Other:
3 - ENTITLEMENTS AND INCOME:
Benefits or Insurance Now Receives Benefits or Insurance Now Receives
Social Security Retirement □ Wages/earned income □
SSI □ Worker’s Comp □
SSD □ Unemployment □
Public Assistance □ Private insurance/third party payer □
Veterans □ Trust fund □
Medicare □ Special needs trust □
Medicaid □ Section 8 □
Food Stamps □ Other □
Pension □ Child support:______□
Client Medicaid #: ______Managed Care Co:______Debts: ______
Representative payee? / □ No □ Yes
Representative Payee Name:
Agency:
Address:
Phone:
4 - CLINICAL INFORMATION-
DIAGNOSES / CODE
DSM 5 MH
DSM 5 SUD
DSM 5 other
Disability level
Chronic health
conditions
Outpatient Treatment Agency:
Therapist: / Phone #:
Psychiatrist: / Phone #:
Last Treatment Program:
Date of Last Service:
Age of Onset of Illness:
List Medications, or attach list:
□ Prescribed oral medications □ Prescribed injectable medications.
□ Symptoms of mental illness interferes with taking medications as prescribed/recommended.
Primary Care Physician:Location of practice:
4 - CLINICAL INFORMATION CONTINUED:
Number of ER Visits For Psychiatric Reasons in the in last 12 Months:______dates:______
Number of Psychiatric Hospitalizations in the last 24 Months:______list dates below:
Date / Hospital / Length of Stay
Substance Use
Drugs of Choice:□ None □ Any IV Drug Use □ Alcohol □ Marijuana/Cannabis
□ Crack □ Heroin/Opiates □ PCP □ Hallucinogens
□ Cocaine □ Sedative/Hypnotic □ Benzodiazapines □spike, synthetic marijuana
□ Prescription drugs □ Amphetamines □ Inhalant: Sniffing glue, other household product
□ Other:______Inpatient rehab?______
Physical Health/Wellness
Check off any of the following that apply:□ Incontinent □ Impaired walking □ Requires special medical equipment
□ Hard of Hearing/Deaf □ Impaired Vision/Blind □ Lung Problems
□ Diabetes □ Heart Problems □ High Blood Pressure
□ Chronic Pain □ Weight Concern □ Cognitive Impairment
□ Speech Impairment □ Developmental Disorder □ Traumatic Brain Injury
□ Learning Disability □ Other: ______
5 - ALERTS RELATED TO RISK TO SELF OR OTHERS:
Yes / No / Date of most recent episode
History of Homelessness
Victim of Physical/ Sexual Abuse
Current Domestic Violence in home
Chronic self-harm/ self-mutilation
History of Suicidal Ideation
History of Suicide Attempts / Self Harm
Elaborate on other serious attempts:
Arson
Physically abusive and/or assaultive of another
Sexually assaultive behavior
Destruction of Property
Current Access to Firearms / n/a
Criminal Justice Involvement
AOT Order
AOT Enhanced
6 – Legal:
Involved with: If incarcerated, anticipated release date:______
□ Treatment Court □ Child Protective Services □ Adult Protective Services
□ Probation □ Assisted Outpatient Treatment (AOT) □ Parole
□ CPL □ Court Order or Diversion □ Other: ______
7- Reason for Referral:
Precipitating Events and Reason for Referral:
______
______
______
Current Symptoms:
______
______
______
Desired Outcome of Care Coordination or Residential services:
______
______
______
Strengths:
______
______
______
If Currently on Inpatient Unit, Please Specify Discharge Plans, Linkages, and Discharge Date:
______
______
______
I am the individual requesting services and agree to the submission of this information and the review of it by the SPOA Team, Health Home care management and/ or residential services. □ YES □ NO Date:
OR
I completed this application for the individual requesting services and they agreed to this submission and review by the SPOA Team and potential providers.
□ YES □ NO Date:
If you do not have income please apply SSI / SSD or DSS Temporary Assistance as soon as possible. / Date applied:
To apply for OMH residential or housing services include the:
“RESIDENTIAL SERVICES DESCRIPTION SELECTION addendum to SPOA application”
Onondaga County SPOA Application/Referral checklist
SPOA Application, includes:
SPOA Permission Form
Assessment and/or progress notes or
Treatment Records
Residential Services Description selection
OMH Priority Verification of Eligibility form (add on for independent housing referrals)
Send application and documents to SPOA Team
SPOA fax: 315-435-3279
Or, to apply for Health Home Care Management for persons with active Medicaid, do not use the SPOA application, use HHUNY Health Home application, or the SJHHC Care Network application
Guidelines-Use the SPOA application and attachments to apply for these adult services:
· OMH Mental Health Residential Programs
· Mental Health Independent Supported Housing Programs (now for OMH and MRT high need candidates only)
· Forensic Case Management (FCM) for people leaving incarceration
· Assertive Community Treatment (ACT); add ACT Referral Summary
Basic Eligibility criteria:
· Be diagnosed with a serious and persistent mental illness (SPMI), at least 18 years old and require support in 2 or more areas of functioning which have been disrupted by a mental illness
(see OMH Priority Verification of Eligibility for clarification)
Send residential/housing applications to SPOA at fax number (315)-435-3279; complete applications will be forwarded to residential providers
Residential Applications are processed by the Residential Agency you choose
For housing challenged individuals, contact SPOA Specialist at 435-3355 x4997
Follow up Documents Needed to Complete Application for OMH Residential Programs:
____Physician’s Authorization for Restorative Services
____Physical ____TB test _____Photo ID