OP Service Referral Form

Referral or Reauthorization Information Form
New or Existing Client*

New Client (Initial)Existing Client (Reauthorization)
Today's Date:*

MonthDayYear
Date
Client Name*
Managed Care Organization (MCO) name*
IME, ITC, Molina, or Wellpoint
Medicaid ID #*
for SUS services Admin will call family if other than Medicaid
Date of Birth*
Parent/Guardian Name(s)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Referral to:*

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?*

Initial (New-Attached Assessment & Treatment Plan)Reauthorization (Attach Updated Treatment Plan)
Diagnosis V-ICD 10 *
Please list diagnosis and code
Client's chosen Pronouns:*
Is family supportive of client's chosen pronouns?*

YesNo
Does this family need Interpretation services?*

YesNo
if so, what Language:
If family uses an interpreter already, please list name, number and email of interpreter:
Problem Areas/Functional Impairments/Target Symptoms:*

Cognitive Flexibility SkillsConflict Resolution SkillsExecutive SkillsProblem Solving SkillsCommunication SkillsEmotional Regulation SkillsInterpersonal Relationship SkillsSocial Skills
Reason for referral*
Suggested Goals/Objectives/Interventions for BHIS (BHIS clients only)*
BHIS Units Requested
H2019 HA Individual (15 min units)*
H2019 HR Family (15 min units)*
If a BHIS group is available, would you recommend client to attend?*

YesNo
Length of time requested:*

6-Months3-MonthsOther
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:*
Community/Family/Service Supports *
Therapy, med mgmt, BHISD, IHH, school or other providers & family members
Clinical Update:*
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?*

YesNo
What were the results:
Have you completed a safety plan with this client?*

Yes, if yes please send a copy of the plan with this referralNo
Social/Medical/Psychiatric/Substance Use History question*
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?*

YesNo
Has this client ever been hospitalized (overnight) for any physical health concern?*

YesNo
Has this client ever been hospitalized (overnight) for any mental health condition?*

YesNo
Does this client have any nutrition needs and/or concerns that may be indicators of an eating disorder?*

YesNo
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)*

NoneIdeationIntent without MeansIntent with MeansContracted not to harm self
How would you rate the client’s overall level of risk of Homicide?*

NoneIdeationIntent without MeansIntent with MeansContracted not to harm others
Physical or sexual abuse or child/elder neglect?*

YesNo
If yes to Physical or sexual abuse, patient is/was:

VictimPerpetratorBothNeither, but abuse exists in family
Any other Risk/Safety Concerns:*
Please list: Safety Concerns/Behaviors/Environment Risks
Therapeutic Treatment Plan Goals, Objectives, Interventions:*
Conclusion & Treatment Recommendations/Additional Comments and/or special accommodations:*
Agency/Credentials/Clinician Name/Email address*
Signature*

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Please upload any other clinical that will be helpful (assessment, clinical notes, etc)

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Date*

MonthDayYear
Date
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Referral or Reauthorization Information Form

LPHA Assessment/Reassessment

Current & Previous Treatment History

Risk/Safety Factors