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Referral or Reauthorization Information Form
Today's Date:
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Month
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Day
Year
Date
Client Name
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Medicaid ID #
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for SUS services Admin will call family if other than Medicaid
Date of Birth
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Parent/Guardian Name(s)
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Email
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example@example.com
Referral to:
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BHIS (Behavioral Health Services)
SOC (Systems of Care Program)
SUS (Substance Use Services)
FOR BHIS ONLY: Is this a New Referral or a reauthorization for services?
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Initial (New-Attached Assessment & Treatment Plan)
Reauthorization (Attach Updated Treatment Plan)
Diagnosis V-ICD 10
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Please list diagnosis and code
Client's chosen Pronouns:
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Is family supportive of client's chosen pronouns?
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Yes
No
Does this family need Interpretation services?
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Yes
No
if so, what Language:
If family uses an interpreter already, please list name, number and email of interpreter:
Problem Areas/Functional Impairments/Target Symptoms:
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Cognitive Flexibility Skills
Conflict Resolution Skills
Executive Skills
Problem Solving Skills
Communication Skills
Emotional Regulation Skills
Interpersonal Relationship Skills
Social Skills
Reason for referral
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Suggested Goals/Objectives/Interventions for BHIS (BHIS clients only)
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BHIS Units Requested
H2019 HA Individual (15 min units)
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H2019 HR Family (15 min units)
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If a BHIS group is available, would you recommend client to attend?
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Yes
No
Length of time requested:
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6-Months
3-Months
Other
LPHA Assessment/Reassessment
Please make sure to include not only Updated Clinical but Clinical History of client or include your Assessment/TP with this form
People Present for Assessment:
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Community/Family/Service Supports
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Therapy, med mgmt, BHISD, IHH, school or other providers & family members
Clinical Update:
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Include all of the following: Significant events since last initial or update assessment, Course & Response to Treatment, Medication Changes, statement about Mental Status Exam (any changes or concerns):
Standardized Outcome Tool used?
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Yes
No
What were the results:
Have you completed a safety plan with this client?
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Yes, if yes please send a copy of the plan with this referral
No
Social/Medical/Psychiatric/Substance Use History question
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co-occurring physical illness):
Current & Previous Treatment History
(outpatient, inpatient, community based, etc)
Is the family in the process of pursuing and/or seriously considering placement in residential programming?
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Yes
No
Has this client ever been hospitalized (overnight) for any physical health concern?
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Yes
No
Has this client ever been hospitalized (overnight) for any mental health condition?
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Yes
No
Does this client have any nutrition needs and/or concerns that may be indicators of an eating disorder?
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Yes
No
Comments on treatment history: (if yes to any of the questions above)
Risk/Safety Factors
How would you rate the client’s overall level of risk of Suicide? (if available, please provide most recent suicide assessment for client)
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None
Ideation
Intent without Means
Intent with Means
Contracted not to harm self
How would you rate the client’s overall level of risk of Homicide?
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None
Ideation
Intent without Means
Intent with Means
Contracted not to harm others
Physical or sexual abuse or child/elder neglect?
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Yes
No
If yes to Physical or sexual abuse, patient is/was:
Victim
Perpetrator
Both
Neither, but abuse exists in family
Any other Risk/Safety Concerns:
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Please list: Safety Concerns/Behaviors/Environment Risks
Therapeutic Treatment Plan Goals, Objectives, Interventions:
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Conclusion & Treatment Recommendations/Additional Comments and/or special accommodations:
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Agency/Credentials/Clinician Name/Email address
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Signature
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Please upload any other clinical that will be helpful (assessment, clinical notes, etc)
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