Make A Referral

Is the primary diagnosis schizophrenia/other psychotic disorder, Major Depressive Disorder-Recurrent, or Bipolar I or II?

YES NO

If NO, a physician MUST have documented any other mental health disorder within the last year to include all of the following: Serious Mental Illness (SMI), Severe and recurrent disability, Functional limitations in the member’s major life activities which are documented in the member’s record; and Member requires individualized training in order to achieve or maintain independent living in the community.

Does the individual require training in acquiring basic living skills such as symptom management; adherence to psychiatric and medication treatment plans; development and appropriate use of social skills and personal support system; personal hygiene; food preparation; or money management?

YES NO

Does the individual have a prior history of any of the following? Psychiatric hospitalization, Crisis Stabilization (any), Intensive Community Treatment (ICT), (PACT) services, Placement in a psychiatric residential treatment facility (RTC Level C); or Temporary Detention Order (TDO) evaluation as a result of decompensation related to serious mental illness.

YES NO

Has the individual had a prescription for anti-psychotic, mood stabilizing, or anti-depressant medications within the last 12 months?

YES NO

PSYCHOSOCIAL REHABILITATION (VIP) CRITERIA MUST MEET 2 OF 4

Does the client experience difficulty in establishing and maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization, homelessness, or isolation from social supports?

YES NO

Does the client experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition or managing finances to such a degree that health or safety is jeopardized?

YES NO

Does the client exhibit such inappropriate behavior that repeated interventions documented by mental health, social services or the judicial system are or have been necessary.

YES NO

Does the client exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate behavior in daily life?

YES NO

CRISIS STABILIZATION CRITERIA MUST MEET 2 OF 4

Is the client having difficulty in establishing or maintaining interpersonal relationships due to the crisis situation to such a degree that they are at risk of hospitalization, homelessness, or isolation from social supports?

YES NO

Is the client exhibiting such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary?

YES NO

Is the client exhibiting difficulty in cognitive ability as a result of the crisis such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior?

YES NO

Does the client’s current crisis cause issues with completing basic living skills, such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized?

YES NO

DATE OF REFERRAL:

PROGRAM(S):

Mental Health Skill Building

Crisis Stabilization

Psychosocial (VIP)

SERVICE AREA

CLIENT INFORMATION

MENTAL HEALTH SKILL BUILDING CRITERIA MUST MEET ALL OF THE FOLLOWING

PSYCHOSOCIAL REHABILITATION (VIP) CRITERIA MUST MEET 2 OF 4

CRISIS STABILIZATION CRITERIA MUST MEET 2 OF 4

PROBLEM AREAS IDENTIFIED FOR THIS CLIENT:

REFERRAL PARTY INFORMATION