Cortland County Single Point of Access (SPOA)
Mental Health Services for Children
THE SPOA REFERRAL PROCESS
1. Please complete the SPOA REFERRAL packet as thoroughly as possible. Make sure to include the signed
Release of Information Form and SED Checklist. If you are unsure of certain information or do not have access
to all information, the referral can still be submitted and reviewed. An electronic version can be found at:
http://www.cortland-co.org/mhealth/Default.htm
2. Make sure to indicate the service(s) being requested (if known). See below for listing of services available
through Cortland County. If the intention of the referral is for HCBS Waiver, please have parent/guardian
complete Request for Screening for Waiver Services form.
3. You can mail the entire referral packet to: Child SPOA, 7 Clayton Ave. Cortland, NY 13045 att. Garra.
Referrals can also be faxed to-(607-758-6116). If you have any questions about the referral form or process you
may contact: Garra Lloyd-Lester at (607) 758-6100 x256 or email at glloydlester@cortland-co.org
4. SPOA meetings are typically scheduled for the first Tuesday of the month from 10:30-11:30 at the Mental
Health Clinic, 7 Clayton Ave. You will be contacted upon receipt of your SPOA referral to discuss service
options and/or a service planning meeting.
Services available through Cortland County SPOA
Below are the services available to eligible* children, ages 5 through 18, who are referred to SPOA:
*Eligible means child must have DSM IV Axis I Diagnosis and be determined Seriously Emotionally Disturbed (SED)-see page #8
1. Family Support Services (includes 5 separate services)--Jamee Sobko, Director (607) 758-6110 x228
(Individuals may make direct referrals to this program as well. Contact Director at number above)
 One-to-one Respite--provides trained Mental Health Program Aides to work one-on-one with an at-risk youth for
approximately 2-3 hours per week. Activities depend on the interests and needs of the child.
 TEAM In -Home Parenting--provides parenting support, advice, and techniques by a trained individual in your
home setting.
 Drop In Respite--provides eligible children with a structured, fun afternoon each week with trained workers.
Children are placed in age appropriate groups and activities vary each week.
 Parent Support Group--an informal support group for parents with high-needs children
 Parenting Classes--facilitated by the Director of Family Support Services, this class offers techniques, advice, and
support for parenting high-needs children.
2. Intensive Case Management--provides case management for eligible* children. There are 39 ICM slots in Cortland
County, with each case manager working with 13 children. Intensive Case Managers help families coordinate
necessary services for their children such as medication management, counseling, and education, as well as desired
programs, activities, and recreation.
3. Home and Community Based Services Waiver--provides the highest level of community based service for eligible*
children. Individual Care Coordinators work with the family to develop a service plan based on the family's unique
strengths and needs. Some of the services families can choose from include: Family Support Services, Crisis
Response Services, Intensive Home Services, Skill Building Services, and Respite Care. There are six slots in
Cortland County for this service and average length of involvement in the program is approximately one year.
4. Residential Treatment Facility Programs--if all Community-based services have been considered or
tried and the child still cannot be maintained in the community, an application to Residential Treatment Facility can
be made. The SPOA committee determines if the RTF referral is appropriate and sends out the referral packet to the
Office of Mental Health Pre-Admission Certification Committee (PACC). Other agencies may need to assist in
gathering documentation and information for the referral packet.
5. Coordinated Children’s Service Initiative (CCSI)-CCSI helps bring families and service providers together to create
a coordinated, comprehensive and strength-based family plan that utilizes multiple systems. A child does not need to
meet the same eligibility requirements noted above in order to access CCSI.
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SPOA REFERRAL FORM
CORTLAND COUNTY CHLDREN'S MENTAL HEALTH SERVICES
Application For:
___ Intensive Case Management (ICM)
___ Home & Community Based Services Waiver (HCBSW)
___ Residential Treatment Facility (RTF) ____ Coordinated Children’s Service Initiative (CCSI) ___ Family Support Services
REASON FOR REFERRAL
Please describe how requested service provision (HCBS Waiver, ICM, RTF, CCSI or Family Support Services) may benefit this child and
family.
CHILD’S NAME: _____________________________________________ DOB: ___________ Age: ___________ Gender: Male
Female
Home Address: __________________________________________________________________________________________________
Home Phone Number: ________________
Cell Number:
Work Number: _____________
Medicaid Status: ___ Current ___Eligible ___ Application Pending ___ Not Applied
Child's Medicaid Number: _________________________________Child's Social Security Number: ________________________________
Parent/Guardians name:
Custody Status: ___ Biological Parents ___ Adoptive
Parents ___ Other family or Legal Guardian ___ DSS ___ Correctional Facility ___Emancipated Minor __Other:___________________________
Is custody being legally contested at this time? ___ No ___ Yes (Explain) ______________________________________________________
_________________________________________________________________________________________________________________
REFERRAL SOURCE NAME: _________________________________________ DATE OF REFERRAL: _____________________
AFFILIATION/AGENCY: _____________________________________________ PHONE NUMBER: _________________________
Relationship to Child: _________________________________
CHILD AND FAMILY HOUSEHOLD INFORMATION
Name (First and Last)
Age
Relationship to Child
Is this individual living at home?
CHILD'S MENTAL HEALTH CRITERIA
*Does Child meet eligibility Criteria for Serious Emotional Disturbance (see Attachment #1)?
*Is this Child at risk of out-of-home placement (see Attachment #2):
A. DIAGNOSIS: Date of last Diagnostic Evaluation: __________________ Performed by: _________________________________________
Axis I: _______________________________________________ Code#: _________________________________________________
Axis II: ______________________________________________ Code #: _________________________________________________
Axis III: ______________________________________________Code #: _________________________________________________
Axis IV: ______________________________________________ Code #:_________________________________________________
Axis V: GAF SCORE: If in treatment, list current GAF score: _______ Date: ________ Provider: _____________________
Past GAF Score: ___________ Date: ____________ Provider: ______________________________
B. IQ Score: __________________________________________ Test Date: ___________/_____________/___________________
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C. Current Medications for Mental Health Issues: (If known)
Name of Medication
Dosage
Who Prescribed
Current Mental Health Treatment:
 Check if unknown
Mental Health Treatment History
Hospital ER or Psychiatric Hospital Admissions
Where?
Dates?
How long?
Therapist?
Number in last
year?
Inpatient Hospitalizations
Psychiatric ER Visits
Outpatient Treatment
Intensive/ Supportive Case Management
Home & Community Based Waiver Program
Therapeutic Foster Care
Crisis Calls
Risk Factors: (Explain below as necessary)
Suicidal (ideation, attempts) (explain below)
Danger to Self
Danger to others
Cruelty to animals
Fire setting
Sexually abusive / inappropriate to others
Running away / elopement
Reckless behavior
Victimization by others
Destruction of property
Depression
Psychotic Behavior
Manic Behavior
Attention/Concentration Difficulties
Eating Disorders
Agoraphobia/School Phobia /other (specify)
Other Anxiety disorders
Drug abuse
Alcohol abuse
Sexually aggressive
Physical complaints
Developmental delays
Inadequate self care
Difficult social relationships/functioning
Developmental Delays/Learning Disorders
Motor functioning
Other (explain)
Unknown
Past
Current
Revised April 2012
Details: dates, frequency, severity etc…
3
1.
Please describe any history of trauma:
2.
Please describe any history of substance abuse:
3.
Other disabilities or medical problems:
4.
Describe current level of functioning in relation to mental health symptoms:
School Information
Name of School District: __________________________________ Name of School: ___________________________________
School Contact Person: ______________________________ Title: _________________________________
Phone Number: ______________________ How long in this school? ___________________________
Teacher: ___________________________
CSE Classification:
___ No CSE conditions
___ Learning Disabled
___ Physically Disabled
___ Multiply Handicapped
___ Emotionally Disturbed ___ Sensory Impaired
___ Other health Impaired
___ Referral to CSE pending
Current Educational Activity (check all that apply)
___ Currently enrolled ___ Expelled ___ Truant ___Suspended (out of school)
Academic Functioning/ Behavior in School: How is the child doing academically? With students? In the classroom?
COMMUNITY SERVICE/COMMUNITY CONTACT INFORMATION
Service
Currently
Has received in past
receives
(Dates)
Service pending
Provider/Contact Person if known
HCBS Waiver
Intensive Case Management
Family Support Services
Day Treatment Program
Individual Therapy
Family Therapy
Psychiatric Medication
Substance Abuse Treatment
OMRDD Services (specify)
Preventive Services- DSS/ Foster Care
Probation
STEPS/ TASA
CCSI
Other Community Involvement: (Please describe any involvement with other community services/ agencies not described above. Give dates, name
of agency, and reason for involvement if known)
Revised April 2012
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FAMILY STRENGTHS
Please describe the family strengths and supports that may be utilized in service provision (interests, hobbies, personal attributes, relatives,
community organization):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Other Information
1.
Legal Status/ History: (Describe any involvement with criminal court, family court, PINS, probation, police, etc. & give dates. Indicate current
status.)
2.
Financial problems that may impact on mental health of child or service delivery:
3.
Environmental Factors that impact on the mental health of the child or service delivery (E.g. housing, neighborhood):
4.
Family Risk Factors (e.g. history of DV, abuse etc.):
5.
What else has been tried to help the child besides any of the services described above?
6.
Please share any other information you think would be useful for the SPOA committee to know in order to make the most informed
decision regarding services.
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AUTHORIZATION FOR
RELEASE OF INFORMATION
Patients Name (Last, First)
………………………………………………
Sex:……………………..Date of Birth………………….
Facility Name:…………………………………………….
This authorization must be completed by the patient or his/her personal representative to use/disclose protected health information, in accordance with
State and Federal laws and regulations. A separate authorization is required to use of disclose confidential HIV related information.
______________________________________________________________________________________________________________
Description of Information to be used/Disclosed: Any psychiatric and/or psychological testing (including IQ), discharge
planning, psychosocial summaries, special education documentation or other relevant information in order
to assist with determining eligibility.
Purpose or Need for Information:
1. This information is being requested:
 by the individual or his/her representative; or
X Other (please describe) by the Cortland County Children's SPOA committee
Mental Health Services Clinic 7 Clayton Avenue
Cortland, NY 13045
SPOA members for Children's Mental Health Case Management include: Mental Health services--specifically SPOA coordinator, Intensive Case
Managers, Clinicians, Family Support Services, Franziska Rackers at BOCES, Department of Social Services, Catholic Charities, Hillside Waiver, Office of
Mental Health, Family Counseling Services, Central New York DDSO, and Director of Community Services.
Youth’s School (List names of Counselors, Principals, or teacher(s): _______________________________________________________
OTHER specific to this referral: ____________________________________________________________________________________.
OTHER specific to this referral: ____________________________________________________________________________________.
2. The purpose of the disclosure is (please describe):
To assess eligibility for Mental Health case management and/or other Community-Based Mental Health services as listed above in SPOA membership. To
assess priority for receiving Mental Health Case Management and/or other Community-Based Mental Health Services as listed above in SPOA
membership.
OTHER: ______________________________________________________________________________________________________.
Organization/Facility/Program Disclosing Information:
From-please check all that apply
Cortland Regional Medical Center
Cortland County Mental Health
School District
Cortland County DSS
Cortland County Probation
Catholic Charities
_____Family Counseling Services
Other-please specify
A.
To: Cortland County SPOA COMIITTEE
(membership listed above)
I hereby permit the use or disclosure of the above information to the Person/Organization/Facility/Program(s) identified above. I understand that:
1. Only this information may be used and/or disclosed as a result of this authorization.
2. This information is confidential and cannot legally be disclosed without my permission.
3. If this information is disclosed to someone who is not required to comply with federal privacy protection regulations, then it may be redisclosed and would no longer be protected.
4. I have the right to revoke (take back) this authorization at any time. My revocation must be in writing on the form provided to me by the
SPOA COMMITTEE.
I am aware that my revocation will not be effective if the persons I have authorized to use and/or disclose my protected health information
have already taken action because of my earlier authorization.
5. I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the
New York State Office of Mental Health, nor will it affect my eligibility for benefits.
6. I have a right to inspect and copy my own protected health information to be used and/or disclosed (in accordance with the requirements of
the federal privacy protection regulations found under 45 CFR 164.524).
B-1. One-Time Use/Disclosure: I hereby permit the one-time use or disclosure of the information described above to the
person/organization/facility/program/committee identified above.
My authorization will expire: 
When acted upon

90 Days from this date;

Other ____________________________________________________________
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AUTHORIZATION FOR RELEASE OF INFORMATION
Facility Name/Agency
Patient/Client Name (Last, First, M.I.)
B-2. Periodic Use/Disclosure: I hereby authorize the periodic use/disclosure of the information described above to the
person/organization/facility/program identified above as often as necessary to fulfill the purpose identified above.
My authorization will expire:
 When I am no longer receiving services from: Cortland County Children's SPOA agencies (listed on other page).
 One year from this date;
 Other _________________________________________________________________________________________________
C.
Patient Signature: I certify that I authorize the use of my health information as set forth in this document.
______________________________________________________________________
(signature of patient/client or personal representative)
_________________________
(date)
_____________________________________________________________________
Patient/Client name Printed
______________________________________________________________________
Personal Representative's Name (printed)
_______________________________________________________________________
Description of Personal Representative's Authority to Act for the Patient/Client (required if personal representative signs)
D.
Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was
provided to the patient/client and/or the patient/client's personal representative.
WITNESSED BY: ________________________________________________________________Date: _______________________
Signature of staff person using/disclosing information
Authorization Provided to: Cortland County Children's SPOA Committee (membership listed on other page).
To be completed by facility or agency:
______________________________________________ _______________________________________
(Signature of staff person using/disclosing information
Title
_____________________
Date
PART 2: REVOCATION OF AUTHORIZATION TO RELEASE INFORMATION
I hereby revoke my authorization to use/disclose information indicated in Part I, to the Person/Organization/Facility/Program whose name and address
is:
Cortland County Children's SPOA Committee
Mental Health Services
7 Clayton Avenue
Cortland, NY 13045
OR OTHER:
I hereby refuse to authorize the use/disclosure indicated in Part I, to the Person/Organization/Facility/Program whose name and address is:
Cortland County Children's SPOA Committee
OR OTHER:
Mental Health Services
7 Clayton Avenue
Cortland, NY 13045
______________________________________________________________________
(signature of patient/client or personal representative)
_________________________
(date)
_____________________________________________________________________
Patient/Client name Printed
______________________________________________________________________
Personal Representative's Name (printed)
_______________________________________________________________________
Description of Personal Representative's Authority to Act for the Patient/Client (required if personal representative signs)
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ATTACHMENT #1: SED CHECKLIST
This form must be completed by a licensed clinician or other mental health professional.
Information can be requested from collaterals.
SED CHECKLIST: To document a child with Serious Emotional Disturbance
MIMINUM REQUIREMENT FOR SED: Criterion A must be met, and both parts of B or C must be met.
Check All That Apply:
Child meets age requirement (less than 18 years of age).
A.
Diagnosis of Emotional Disturbance. A DSM IV Diagnosis OTHER than:
 Alcohol or drug disorders (291.X; 292.x; 303.x; 304.Xx; 305.Xx).
 Organic Brain Syndromes (290.xx, 293.xx, 294.x).
 Developmental Disabilities (299.xx; 315.xx-319x).
 Social Conditions (v Codes)
 ICD-9-CM Diagnoses Not having a DSM IV equivalent
B.
Extended Impairment in functioning Due to Emotional Disturbance. (Both parts of B must be met.)
I.
Over the last 12 months, continuously or intermittently, youngster has experienced functional limitations due to
emotional disturbance. Problems must be moderate in at least two areas, or severe in at least one area.

Self Care-Personal hygiene; obtaining and eating food; dressing; avoiding injury

Family life-Capacity to live in a family or family like environment; relationships with parents.

Social Relationships-establishing and maintaining friendships; interpersonal interactions
o with peers, neighbors, and other adults; social skills;

Compliance with social norm; play and appropriate use of leisure time.

Self-Direction/Self-Control-ability to sustain focused attention for long

Periods of time to permit completion of age-appropriate tasks; behavioral

Self-control; appropriate judgment and value systems; decision-making ability.

Learning Ability-school achievement and attendance; receptive and

Expressive language; relationships with teachers; behavior in school.
II. During last 12 months, continuously or intermittently, child has rated 50 or less
on the Children’s Global Assessment of Functioning (GAF) because of emotional disturbance.
C.
Current Impairment in Functioning with Severe Symptoms (Both parts of C must be met)
I.
Child currently rates 50 or less on the CGAS or GAF because of emotional disturbance.
II.
Within the past 30 days, youngster has experienced at least one of the following:

Serious suicidal symptoms or other life-threatening, self-destructive behavior

Significant psychotic symptoms (hallucinations, delusions, bizarre behavior)

Behavior caused buy emotional disturbances that placed the youngster at risk of causing

Personal injuries or significant property damage.
Signed By:
Title:
Date:
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Attachment #2
A.
AT RISKOF OUT-OF-HOME PLACEMENT CHECKLIST
To document child at risk of out-of-home placement
Check all that apply:
______ Child meets age requirement (under 18).
______ Failed adoption(s)
______ Parent with serious/persistent mental illness.
Child has experienced at least one of the following:
______ Has been a victim of physical, emotional, or sexual abuse or severe neglect
______ Has been a victim of, or witness to, serious violent crime or domestic violence
Has experienced residential disruption caused by:
______ Out-of-home placement due to emotional disturbance.
______ Multiple family separations.
______ Extended period of homelessness.
B.
Child is at risk of residential placement if any one of these conditions is met:
______ There is a current psychiatric/psychological evaluation recommending placement
______ CSE has approved or is considering residential placement
______ There is a pending application for RTF before the PACC
______ Request for placement has been received by the DSS residential placement unity
______ Child is awaiting placement through the juvenile justice system
______ Child has experienced a previous residential placement
STOP HERE FOR COMMUNITY SERVICES. FOR WAIVER SERVICE, PLEASE COMPLETE NEXT FORM TITLED
"REQUEST FOR SCREENING FOR WAIVER SERVICES."
Revised April 2012
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REQUEST FOR SCREENING FOR WAIVER SERVICES
NAME OF CHILD: ______________________________________________________
CURRENT ADDRESS: __________________________________________________
I am requesting that my child's referral packet be submitted to the ICC Agency and the Local Governmental Unity for screening of
eligibility to apply for the Homer and Community Based Services (HCBS) Waiver. I also understand that the request for screening is
not an application for enrollment in the HCBS Waiver.
I understand that the referral packet will be checked for completeness. The ICC agency may need to contact me or the referral source
for further clarification, or to request additional documentation.
I believe my child qualifies for the waiver because he/she:







Is between 5 and 18 years of age.
Meets the definition of serious emotional disturbance.
Requires or is at imminent risk of needing psychiatric inpatient services for individuals under 21.
Has complex health or mental health care needs.
Has a service and support need that cannot be met by just one agency.
Is capable of being cared for in the community if provided appropriate access to waiver services.
Has a viable and consistent living environment and I am willing to participate in the HCBS Waiver and support my child at home
and in the community.
I understand that if my child is enrolled in the HCBS Waiver he/she may receive waiver services and any needed services available
under the Medicaid State Plan for which he/she is eligible with the exception of Intensive Care Management, Therapeutic Foster Care,
or other waiver programs.
I understand that this screening is necessary before we make formal application to the HCBS Waiver for children and adolescents with
serious emotional disturbance.
Parent/Guardian Signature: _________________________________ Date: __________
Parent/Guardian Name (print): ______________________________________________
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