PM FORM 3.17.2
REQUEST FOR OUT-OF-HOME ADMISSION: ADULT
This Request is to be completed (typed) by the current treating clinician or case manager
if RBHA funding for a behavioral health placement has been requested.
Send by secure fax to 1-866-601-0111
Incomplete or handwritten forms will be returned to sender.
Date of Request:
Request1: ☐Behavioral Health Residential Facility (BHRF) ☐Behavioral Health Therapeutic Home (BHTH)
If requesting a BHRF: Is the request for ☐SUD or ☐mental health treatment or ☐both?
Member’s name:
SSN:
Age:
CIS#: ____
DOB:
AHCCCS ID#:
Mailing address:
Gender:
______________________
City/State/Zip:______
____
Street address:________________________________________ City/State/Zip:___
Member’s primary language: ☐English ☐Spanish ☐Other (specify):
☐COT for DUI ☐COT for DV ☐COT for other: _____________________ ☐Voluntary status
Requested by: ☐Member ☐Court ☐DES (APS/DDD) ☐DOC ☐Family ☐OHR ☐PO
GSA: ☐2 ☐3 ☐4
Behavioral Health Category: ☐GMH ☐SMI ☐SA
Funding source: ☐T19 ☐T21 ☐SAPT ☐Other:
If in a substance abuse priority population: Primary SUD diagnosis:
☐Pregnant female ☐Female with dependent children ☐Intravenous drug user
Where is the member currently living? ☐Home ☐DOC ☐Hospital ☐Jail ☐Respite ☐Shelter
☐Other:
If other than home, admission date:
Name of facility:
If applicable:
Legal guardian:
Street address:
Phone/Extension #:
Fax #:
City/State/Zip: _______________
Legal guardian’s primary language: ☐English ☐Spanish ☐Other (specify):
Intake agency:
Name of person completing request:
Staff e-mail:
Phone #:
Ext:
Fax #:
1
BHRF was formerly known as TGH or L3GH. BHTH was formerly known as Adult Therapeutic Foster Care.
PM Form 3.17.2
Revised 12/3/2015
Page 1 of 5
Has an executive staffing been held at your agency regarding this OOH request? ☐No ☐Yes
If not, why not?
Why is an out of home intervention being requested at this time? (include recent behaviors, psychiatric
symptoms, psycho-social stressors, etc. Documentation should focus on up to the last 3 months with an
emphasis on the last 30 days):
Are there stressful events, losses or traumas that contribute to the member’s current needs? ☐No ☐Yes
If yes, describe below if not previously documented above:
What is the member’s baseline or usual level of functioning? (How was the member functioning prior to the
onset of above issues/events? How long ago was this?)
Please describe the member’s functional strengths:
Please describe the member’s functional impairments:
Who is the member’s support system? (Describe family/community supports available for this member):
Current DSM Diagnoses:
Member’s Name:
PM Form 3.17.2
Revised 12/3/2015
Page 2 of 5
Medical issues, illnesses, impairments, disabilities or unique challenges? ☐No ☐Yes If yes, list below.
Substance Use History: ☐No ☐Yes If yes, complete the following table
Class Of Substances
Alcohol
Amphetamines (Meth)
Cocaine/Crack
Hallucinogens
Inhalants (glue, paint, aerosols)
Marijuana
Age at
First Use
Amounts Used
Frequency of
Recent Use
Date of
Last Use
Opiates (prescription abuse, heroin)
Other (specify)
Previous behavioral health/substance abuse placements: ☐No ☐Yes
If yes, complete the following table (add rows as necessary).
Dates
Provider/Level of Care
Length of Stay
Discharged To
Outpatient Services: Please check any and all services that have been provided within the last 90 days to
address the clinical needs that are driving this referral:
☐None ☐Behavior coach ☐Crisis stabilization team ☐Dialectical Behavior Therapy (DBT)
☐Family counseling ☐Functional Behavioral Analysis (FBA) ☐Home-based therapy
☐Independent living skills ☐Individual counseling ☐Medication management ☐Other in-home services
☐Parent partner ☐Peer Support ☐Respite ☐Skills training and development
☐Substance abuse IOP ☐Vocational assessment & training ☐Other:
The following agencies have provided the above services:
Medications*: ☐No ☐Yes. If yes, list current medication information below:
Medication and Dosage
Directions
Medication Adherence
☐Full ☐Partial ☐Poor
☐Full ☐Partial ☐Poor
☐Full ☐Partial ☐Poor
☐Full ☐Partial ☐Poor
☐Full ☐Partial ☐Poor
*If a behavioral health medical professional (BHMP) has not evaluated this member, please schedule an
evaluation and provide the date:
and the evaluator’s name:
Member’s Name:
PM Form 3.17.2
Revised 12/3/2015
Page 3 of 5
Stakeholder Information
 Legal History: ☐No ☐Yes If yes, offenses/reasons for arrests:
Currently on probation: ☐No ☐Yes Type: ☐Standard ☐IPS ☐Sexual Offender
Probation Officer:
Phone/Extension:
Fax #:
Currently on parole: ☐No ☐Yes
Parole Officer:
Phone #:
Fax #:
Currently detained? ☐No ☐Yes If yes, since when:
Where:
Next court date:
 Current Adult Protective Service (APS) involvement? ☐No ☐Yes If yes:
When and why did APS become involved?
 Current Division of Developmental Disabilities (DDD) involvement? ☐No ☐Yes If yes:
DDD Case Manager:
Phone/Extension:
Fax #:
 Does this Member belong to any other specialty population? ☒No ☐Yes If yes, please specify:
☐Homeless ☐Native American ☐Pregnant ☐Sensory Impaired:
☐Other:
Have the risks of an out-of-home placement been discussed with the member? ☐No ☐Yes
If no, describe why this has not occurred.
If placed, which family members or community supports will be involved in the member’s treatment?
What are the goals and objectives for this proposed placement?
What are the discharge criteria for this proposed placement? Detail specific improvement being sought for
any barrier to discharge to the community for further care.
What is the estimated discharge date?
Member’s Name:
PM Form 3.17.2
Revised 12/3/2015
Page 4 of 5
What is the preliminary discharge plan?
Include the expected outpatient services and community supports to be provided for the member to succeed
in the community and prevent subsequent out of home placements.
Checklist for OOH Admission request:
ART notes for the past 30 days
ASAM if request is for OOH substance abuse treatment
Completed Request for Adult OOH admission
Current Behavioral Health Service Plan
Most recent psychiatric evaluation
Psychiatric progress notes for the last 30 days
Psychological/psycho-educational evaluation(s)
Discharge summaries from any previous inpatient or residential facilities.
Other:
Member’s Name:
PM Form 3.17.2
Revised 12/3/2015
Page 5 of 5