Baltimore Mental Health Systems, Inc.
APPLICATION FOR RESIDENTIAL REHABILITATION PROGRAMS
(Revised 11/10)
This application is to be used for individuals requesting residential placement in Baltimore
City. These services are coordinated by the Adult Services Team at Baltimore Mental Health
System, Inc. (BMHS). Placements are in licensed Residential Rehabilitation Programs
(RRP). The purpose of this application is to provide essential information needed to
evaluate eligibility for services, and the level of care needed by the applicant. Services are
available to adults (18 years of age or older) with priority given to Baltimore City residents
with a severe and persistent mental illness. Upon receipt of the completed and signed
application, the applicant will be referred to a program with a vacancy or placed on a waiting
list if no vacancy is available.
Two signatures by the applicant (client) must be enclosed with the application.
This application is for:
_________________________________________________________________
Client name
_________________________________________________________________
Referral Source: Name
Agency
Phone #
_________________________________________________________________
Agency Address
Please feel free to call Baltimore Mental Health Systems, Inc. at (410) 837-2647 with
any questions or concerns. Please return the completed application and, if possible, a
copy of the most recent psychosocial assessment or psychiatric evaluation. All
sections of the application must be completed. Please put “N/A” when
something is not applicable.
Baltimore Mental Health Systems, Inc.
201 E. Baltimore St., Ste 1340
Baltimore, MD 21202
Office# 410-837-2647
Fax# 410-837-2672
BALTIMORE MENTAL HEALTH SYSTEMS, INC.
APPLICATION FOR RESIDENTIAL REHABILITATION SERVICES
(I) Today’s Date:___________________
Applicant’s Name: (Last)
(First)
(M.I.)____
Last known address in community:
______________________________________________________
______________________________________________________
Telephone #
.
Date of Birth:
Social Security#:______________________
Gender:______________ Race:________________
Marital Status:_______________________________
Current Entitlements and Income (Fill in amounts and/or insurance numbers)
SSI
SSDI:
Other Income:___________________
Medicaid (MA)#
Medicare #:_________________________
Other Insurance Name & Number:_______________________________________________
(II)Referral Source Name:
Agency:_________________
Telephone # ________________________________ Fax #___________________________
Psychiatrist Name
Telephone #__________________
Other Providers (Mobile Treatment, PRP, Case Management, Outpatient)-(please circle)
Name of Program
Contact Person
Telephone#
Primary Contact (applicant, therapist, family, member, friend, other)-(please circle)
Name of Contact
Telephone #
Relationship to Applicant
________________________
____________________
_______________________
(III) Current Psychiatric Diagnosis:
DSM-IV Codes:
Axis I:
___________________________
_______________________________
___________________________
Axis II:
___________________________
_______________________________
___________________________
Axis III:
Axis IV:
Axis V: (GAF)
Number of psychiatric hospitalizations:_________
List psychiatric hospitalizations (current or most recent first):
Date
Location
Admission
Discharge
.
.
.
.
.
.
Applicant’s Name________________________________ DOB _______________________
(IV) Name of Primary Care Provider (PCP):________________________________________
Address:______________________________________________________________________
Telephone #:__________________________
Somatic Issues:________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(V) All Current Medications: (Psychiatric and Somatic)
Current
Name
Dosage-Frequency
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Current ability to take medicine:
Independently
With reminders
With daily supervision ____________
Refuses medication
Meds not prescribed ______________
Comments:
(VI) Legal History/Forensic Involvement
Has the applicant ever been arrested? Y
N_____
On Probation or Parole? Y
N_____
List any reported convictions
______________________________________________________________________________
______________________________________________________________________________
Parole or probation officer & Phone #:
Has applicant been found NCR? Y
N_____
Is on (or will be on) conditional release? Y
N_____
(VII) Substance Use/Abuse History
Drug Used (including alcohol) Period of Use
Frequency
How Used
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Drug Last Used
Date
Amount
How Used
________________________________________________________________________
Substance Abuse Treatment History (date and location)
A.A._______________________________ N.A. ________________________________
Detox _______________________________________________________
Inpatient Services ________________________________________________________
Outpatient Services_______________________________________________________
________________________________________________________________________
Applicant’s Name
DOB______________
(VII) Risk Assessment (Never, past week-month, past month-year, past 2+years)
Suicide Attempts:_________________________________________________________
Suicidal Ideation:_________________________________________________________
Aggressive Behavior/Violence:_____________________________________________
Fire Setting:_____________________________________________________________
(IX) Activities of Daily Living
Independent;
Needs moderate support;
Needs significant support
(X)Previous RRP involvement? Yes____ No _____ If yes, reason for discontinuation of RRP
Consumer preference of provider
__________________________________________________
Cultural preference of consumer _________________________________________________
(XI)Rationale for Service:
(Please include major areas of need and applicant’s goals for RRP)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Recommended Level of Residential Placement:
General Level (General support means staff are available, on-call, 24 hours per day,
7 days a week and provide a minimum of one face to face contact per
individual per week.)
Intensive Level
(Intensive support means staff provide daily off-site services in the resident
with a minimum of 40 hours per week up to 24 hours a day, 7 days a
week.)
(RRPs at both levels of care provide on-call availability 24 hours per day.)
(XII)Is the applicant in agreement with the above referral?
If "No", explain :
Y
N
_____________________________________________________________________
Referral Source Signature
Date
Please review application to ensure it is complete and all sections are filled out.
Baltimore Mental Health Systems, Inc.
Residential Rehabilitation Programs (RRPs) in Baltimore City
Residential Rehabilitation Programs are designed to assist those who have a serious mental illness
and are in need of psychiatric rehabilitation in a supervised residential setting (assistance with
Activities of Daily Living, community integration, medication monitoring, etc.) There two types of
levels available:
General Support- Staff are available on-call 24 hours per day, 7 days per week, and provide at a
minimum one face to face contact per individual, per week.
Intensive Support- Staff provide services daily on site in the residence with a minimum of 40
hours per week up to 24 hours per day, 7 days per week.
The housing provided is furnished and supervised by staff. All residents are expected to contribute
to the cost of their care. Money for food and personal needs is allotted. Typically, the households
are comprised of 2 or more residents. Residents have rights and responsibilities, and each program
has their own unique variances to the rules that need to be followed. The residents are responsible
for housekeeping. A productive daytime activity is required for residing in RRP. The goal of
residential rehabilitation is to work towards independent living.
I have read the description of Residential Rehabilitation above and I understand that:
1.
2.
3.
4.
I will be living with others, but have my own room
I will be assisted by staff
I will be required to follow rules and participate in a day activity or work.
I will be required to contribute to the cost of my care.
I wish to apply for the service
________________________________________________________________________
Client Signature
Date
________________________________________________________________________
Referral Source Signature
Date
CONSENT TO RELEASE INFORMATION
FOR RESIDENTIAL PLACEMENT
I give my consent to
(CSA)
to release this application and other clinical and psycho-social history to a
Residential Rehabilitation Program in order to assess my eligibility for residential
services in the community.
I understand that this information will not be released to any other party without my
express written consent.
I further understand that my consent does not commit me to accept a placement,
and it does not commit the Core Service Agency to provide a placement for me.
I understand that I may revoke this consent at any time by a written statement. This
consent is valid for 12 months from the date of my signature.
Signature:
Date:
Social Security #:___________________
__
Date of Birth:
Witness:_________________