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External Referral for Mental Health Skill Building

Date of Referral: *

Medicaid Recipient: *

Client's Name: *

First

Last

Client's Phone Number *

Reason for Referral: *

Does the Client Meet the Following Criteria?

Have a need for individualized 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. *

Have a qualifying mental health diagnosis (psychotic disorder, major depressive disorder –recurrent, or bipolar disorder I or II). *

If an individual has another disorder, it will qualify if a physician determines:

it is a serious mental illness
it results in severe and recurrent disability that produces functional limitations in major life activities, and
the individual requires individualized training in order to achieve or maintain independent living in the community

Have a prior history of qualifying mental health treatment. *

*A qualifying mental health treatment is considered at least one of the following:

Psychiatric hospitalization
Residential treatment
Residential crisis stabilization
PACT or ICT services
RTC-Level C placement
A TDO evaluation due to mental health decompensation

Referral Source: *

Referral Phone Number:

Parent/Guardian's Name: *

First

Last

Parent/Guardian's Email *

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External Referral for Mental Health Skill Building

Does the Client Meet the Following Criteria?

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