CROSSROADS COMMUNITY_ INC by fjhuangjun

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									                                       CROSSROADS COMMUNITY, INC.
                                     CASE MANAGEMENT REFERRAL FORM

                                         Send Case Management Referrals to:
                            Crossroads Community Case Management Program Coordinator
                                                   P.O. Box 718
                                               Centreville, MD 21617
                                            Phone: 410-758-3050, ext. 44
                                               FAX: 410-758-1223
                                     PLEASE COMPLETE ALL SECTIONS
                                       Please Include the Following: (Check if attached)
                                                           ____ ITP
                                                  ____ Psycho-Social History
                                ____ Psychiatric Evaluation
_______________________________________________________________________________________
For CCI use only :
                                General CM__________                               Intensive CM____________

Value Options/CSA Authorization Number: _____________________
Authorization Period: ______________
Date Authorization Requested:_____ Received: _________

                                                 CONSUMER INFORMATION
Name                                                                  DOB                      Gender: M F
Marital Status: Single ___            Divorced___          Married___       Separated___   Other___
Address
Town:                                   County                                State          Zip Code
Phone                                   Cell Phone ___________________                Work Phone #
Legal Guardian (if applicable):
Guardian Address (if different from above):
Town:                                   County                                State          Zip Code
Phone                                   Cell Phone                            Work Phone #
Is client a veteran: Yes____          No_____
Race:
 African American              American Indian/Alaskan                                      Other (explain)
 Hispanic                         Native                                                      Ethnicity:
 Biracial                      Asian American/Pacific                                       Hispanic
 White                            Islander                                                   Non-Hispanic
MA # _____________________________________________
PAC or Gray Zone #                                                           SS#
FINANCIAL INFORMATION:
   SSDI                    Amount
   SSI                     Amount
   Employed
   Unemployed

          Rev. 1/04,4/04, 11/05; 12/06; 9/07; 2/08; 8/09          1                                              CM-02
Current School/College                                                            Special Ed Student? Y N
Grade/YR:_______                        H S Graduate? Y N                College? Y N
Please provide additional information about Education history:



                                                        REFERRAL SOURCE
Name                                                                              Referral Date
Agency
Address
Phone                                                                    Fax

                                              CURRENT DSM-IV-TR DIAGNOSIS
Axis I:                                                                   DSM-IV Code:
Axis II:                                                                  DSM-IV Code:
Axis III:                                                                 DSM-IV Code:
Axis IV:                                                                  DSM-IV Code:
Axis V: Current GAF: __________________________________ Date:
           Highest GAF in last year:                                      Date:


                          The following eligibility criteria must be met in order to receive
                                    Mental Health Case Management Services.

                                                         Priority Populations

The individual must be in a federal eligibility category for and is enrolled in the Maryland Medical
Assistance Program according to COMAR 10.09.24. Services shall be provided to participants who have
a serious and persistent mental health impairment as recognized by the DSM IV-TR, and who are:

           PLEASE CHECK CRITERIA UNDER APPROPRIATE POPULATION
                           Children and Adolescent Criteria (minors under the age of 18)
           A) Children and adolescents with serious emotional disturbance who are in or at risk of:

                    ___       i) Inpatient psychiatric treatment
                    ___       ii) Treatment in a Residential Treatment Center (RTC), or,
                    ___       iii) An out of home placement due to multiple life stressors

                                                     Adult Criteria
           B) Adults with a serious mental illness who are:

                    ___       i) At risk of going into, or will be released from, an inpatient hospital stay
                    ___       ii) homeless or in Shelter Plus Care,
                    ___       iii)Residing in independent housing and in need of services to retain their housing, or,
                    ___       iv) Being released from a detention center.




            Rev. 1/04,4/04, 11/05; 12/06; 9/07; 2/08; 8/09        2                                         CM-02
                                                            Eligibilty Criteria

     Participants shall meet the above requirements and be classified according to the following
     levels of service: (Please circle all that apply).
             a. Level I – General: Based on the severity of the participant’s mental illness, and the
                 participant meets at least one of the following conditions:
                      i. Not linked to mental health and medical services;
                     ii. Lacks basic supports for shelter, food, and income;
                    iii. Transitioning from one level of care to another level of care; or
                    iv. Needs to maintain community-based treatment and services;

               b. Level II – Intensive: Based on the severity of the participant’s mental illness, and the
                  participant urgently meets more than one of the following conditions;
                       i. Not linked to mental health and medical services;
                      ii. Lacks basic supports for shelter, food, and income;
                     iii. Transitioning from one level of care to another level of care; or
                     iv. Needs to maintain community-based treatment and services;

Please provide a clinical narrative to justify the need for Case Management
services:______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
                                                      SERVICE PROVIDERS
Primary Somatic Health Care Provider:
Name:                                                                                       Phone
Address:
Primary Therapist (Mental Healthcare/Clinical): Agency:
Name:                                                                                       Phone:
Address:
                                                   CURRENT MEDICATIONS
Rx__________________________________________________                                 Dosage_________________________
Rx__________________________________________________                                 Dosage_________________________
Rx__________________________________________________                                 Dosage_________________________
Rx__________________________________________________                                 Dosage_________________________
Rx__________________________________________________                                 Dosage_________________________
Rx__________________________________________________                                 Dosage_________________________
HOSPITALIZATION OR PLACEMENT HISTORY: (Include RTC, group homes, foster, hospitalization, jail)
How many years has this client received mental health services?
Currently inpatient or incarcerated?            Yes          No     If Yes, Projected D/C Date:
If inpatient, does this patient currently have off-grounds privileges without staff?              Yes   No N/A ___
Hospital/Prog:                                                              Dates:
Hospital/Prog:                                                              Dates:
Hospital/Prog:                                                              Dates:
Hospital/Prog:                                                              Dates:

           Rev. 1/04,4/04, 11/05; 12/06; 9/07; 2/08; 8/09           3                                       CM-02
Allergies or Reactions to Medications:


Dietary Restrictions:


EMERGENCY CONTACT (If other than Legal Guardian) (Required for Consumers under 16):
Name:                                                          Relationship:         Phone:
Address:
OTHER AGENCY INVOLVEMENT
   DDA                  DSS                 DJS             ADDICTIONS
   Other:

                                     RISK BEHAVIOR & PRESENTING PROBLEMS
            Behavior/Problem (if current, the problem MUST be explained)                Current History
Suicidal/Homicidal Threat/Attempt (give date of most recent occurrence)
Explain:

Chronic Health Problems/Medical/Somatic/Physical Impairment or Disability Explain:



Substance Abuse
Explain:

Learning Difficulties/School or Vocational Problems
Explain:

Legal Issues (charges, delinquent behavior, probation, etc)
Explain, if COR:

Runaway Behavior
Explain:

Malicious Destruction of Property
Explain:

Sexual Issues (aggressor, promiscuous)
Explain:

Abuse/Assault/Trauma Victim
Explain:

Chronic Anger/Aggression (physically, verbally, weapon involved etc.)
Explain:

Social Interpersonal Conflicts
Explain:


           Rev. 1/04,4/04, 11/05; 12/06; 9/07; 2/08; 8/09      4                              CM-02
Family Problems/Peer Conflicts
Explain:

Coping With Daily Roles & Activities
Explain:

Depression/Mood Disorder
Explain:

Eating Disorder
Explain:

Thought Disorder
Explain:

Other (e.g. fire starter, self mutilation, hallucinations)
Explain:



What services or additional linkages does the client need at this time? (Circle all that apply)
Family:                         Respite                      Family Therapy       Other (explain)
Psychological:                  Therapist                    Psychiatrist         PRP                  Group Therapy
                                Substance Abuse Tx           Neuropsychological   Other
Housing:                        Section 8                    Subsidized Housing   ER                   Shelter
                                Other (explain)
Medical:                        Primary Care Doctor          Dentist              Pain Clinic          Other (explain)
Education:                      School Advocate              GED Program          School Assessment    School Meeting
                                Other (explain)
                                Supported
Employment/Vocational:                                       Other (explain)
                                Employment
Transportation:                 Public Transportation        Other (explain)
Financial/Entitlements:         Medical Assistance           MA Buy-In Prog.      SSI/SSDI             DEAP
                                TCA/TEHMA                    Food Stamps          Other (explain)


                                          CONSUMER REFERRAL AGREEMENT
I (guardian/self)                                                                 agree to the referral for Case Management
services from Crossroads Community, Inc.

I authorize                                                                               (referral source) to
release/exchange information to Crossroads Community, Inc. for the purpose of facilitating the disposition of the
referral. I understand that the information exchanged may include the diagnosis, evaluations and records of
progress.

I understand that this authorization is valid for one year from the date of signing, and that I may retract it in writing
at any time.

Signed:                                                                           Date:

Parent/Guardian:                                                                  Date:


           Rev. 1/04,4/04, 11/05; 12/06; 9/07; 2/08; 8/09             5                                     CM-02

								
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