UMass ID/MH Evaluation Team Referral Form and Intake Procedure
The UMass Intellectual Disabilities/Mental Health (ID/MH)
Consultation Team
Dr. Laurie Charlot, Director
Adult Neurodevelopmental Disabilities Initiative (ANDI)
295 Lincoln Street
Worcester, MA 01655
Phone: 508-334-6693
charlotl@umassmemorial.org
fax 508-334-2029
Intake coordinator: Don Northway
Phone 508-334-2013
Contact for contracting and billing:
Deborah Dedmon
508-856-6578
PLEASE TYPE INTO THE FORM AS A WORD DOCUMENT AND SAVE IT-PLEASE
DO NOT HAND WRITE
PLEASE FILL OUT THE FORM AS COMPLETELY AS POSSIBLE, AN SEEK INPUT
FROM OTHERS WHO KNOW THE PATIENT WELL
IF POSSIBLE, SEND VIA EMAIL SECURELY
Overview of the Process:
1. Case is accepted as appropriate for evaluation and a date for the face to face
visit is assigned
a. PLEASE BE SURE TREATING CLINICANS KNOW THIS EVALUATION
IS TAKING PLACE AND ARE OPEN TO HEARING FROM THE UMASS
TEAM so we can insure maximum benefit of the assessment
2. Referring source sends a completed referral packet
3. UMass team reviews the referral packet
4. Members of the UMass team conduct a pre-visit or have a phone conference to
gather initial information
5. Face-to-Face visit to the UMass clinic – see description of the day of the visit
below
6. Follow up phone calls may occur to gather additional information or more
historical or medical records may be requested.
7. In 30 days, a multidisciplinary report will be sent summarizing our findings and
recommendations.
8. If requested, we will arrange a final conference call or meeting to review the
report and answer questions.
9. If requested, and funding is available, we are able to do some limited follow-up.
Please discuss this with Dr. Charlot. This will include things like helping to get a
behavior plan designed and launched, or providing additional mini consultations
regarding an evolving medical/neuro or psychopharm plan by collaborating with
the treating MDs.
NOTE : Referral packets should be sent to Dr. Charlot
Please include ALL of the following documents, or as many as possible. These can be
faxed, e-mailed or mailed (secure please) – the more complete the packet, the better we
are able to help the patient.
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UMass ID/MH Evaluation Team Referral Form and Intake Procedure
Important documents for the UMass ID/MH Consult Team
PLEASE SEND as complete a referral packet as possible to help us do the best job
possible for your referral:
_______Intake and referral form (attached) completed with accurate identifying data
o We are grateful if you can fully complete the form rather than stating
– see attached, or leaving many spaces blank
o All of the questions on the referral form are important to our assessment
_______ Please attach a copy of the most current Medication Administration Records
_______ Psychopathology Instruments
o The Aberrant Behavior Checklist
o The MASS (Mood & Anxiety Symptom Survey)
o Recent Stressors Questionnaire
o Compulsive Behavior Checklist
o SMASH form (Survey of Medication Associated Symptoms and Health)
_______ Release of Information form
_______ Notes from Psychiatry visits
_______ Any psychiatric consultation reports
_______ Initial visit summaries from psychiatrist
_______Any chart documents in which medical, developmental or behavioral health
history has been summarized
_______ Copy of the most recent Annual Physical
Reports of any medical tests or studies such as CTs, UGIs, MRIs, EEGs, etc.
o Please secure copies and send the original reports or preferable CDs or
DVDs with the study so our MDs can review them directly
_______ Lab reports
_______ Notes from PCP visits
_______ Notes, reports from any other medical specialty (neurology, genetics, GI, etc.)
_______ Discharge summaries from any hospitalizations, medical or psychiatric or from
Emergency Room visits
_______ OT or PT evaluations or reports
_______ Behavior Plans
_______ Graphed behavioral data or other summaries of data
_______ Incident reports or ABC recordings
_______ Psychological test reports
_______ Sleep charts or BM charts
The DAY of VISIT to the UMass Multidisciplinary ID/MH Team
Please come 15 minutes before the appointment time to park and check in. The patient
should come with several informants/caregivers or people who can support him or her
and who know the patient well, including family, service coordinator, case manager,
psychologist, nursing or NP if involved, day program, residential or school if involved etc.
Patient is seen by the UMass ID/MH consult team MD for a Physical Exam first while the
psychologist and psychiatrist interview informants. Then the psychiatrist and
psychologist interview the patient. This all takes 30 mins to 1 hr, depending on the
patient’s tolerance for the process. After the direct patient evaluation, the patient can go
with a staff or other support person for a snack, or go home , while all of the rest of us do
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UMass ID/MH Evaluation Team Referral Form and Intake Procedure
a wrap up - without the patient present - with informants, with our full team, for another
30-45 minutes - the entire evaluation process is about 1 1/2 hours long.
The goal is for us to get a good examination of the patient, and ask questions to fill in our
information we have already reviewed from the extensive referral packet and
questionnaires, to learn more about history of the problems. We later may make more
calls, the psychologist may visit the home of a patient or day program, and eventually in
about 30 days, you will get a large full, multidisciplinary report with our assessments and
recommendations, with at least either a PCP or Neurology, and always with Psychiatry
and Psychology components. Occupational therapy will also evaluate the patient when
appropriate.
Other Considerations
After this comprehensive evaluation is reviewed by the community team/family or others,
we will be available for a follow up phone conference to discuss findings and
recommendations.
It is critical that clinicians providing care are open to the idea of pursuing new ideas and
approaches that might be produced in the consultation process and this has been
established before the consultation has been sought.
Clinic Location:
The new UMass ID/MH Clinic is at 295 Lincoln Street Worcester MA in the 2 story
outpatient medical building, located to the left of Hahnemann Hospital at 281 (if facing
the hospital from Lincoln Street). We are Suite 107 on the first floor on the right when
you enter the building.
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UMass ID/MH Evaluation Team Referral Form and Intake Procedure
INTAKE AND REFERRAL INFORMATION
IDENTIFYING DATA
Name of Patient:
Date of Referral:
Main Contact for this referral:
Address:
DOB:
Patient’s Home Phone:
SS#:
Religious Affiliation:
Insurance Type
Medicaid
Medicare
Other list
DDS or DMHS Area or Region:
MBHP
BC/BS
DATE OF CLINIC EVALUATION VISIT:
Important Contacts Please List NAME and PHONE NUMBERS, E-MAIL
Name/Agency
Phone Number
E-Address
DDS,DMH case
manager:
Residential
agency/contact
Vocational
Placement/contact:
Guardian:
Psychiatrist:
Primary Care
Physician:
Neurologist
Other: List
Therapist
**** The treating Primary Care Clinician/Doctor knows about this evaluation:
____YES ____NO
The treating Psychiatric Clinician/Doctor knows about this evaluation:
____YES ____NO
_____Group residence
_____Supported living
_____Group respite
_____Foster care/Individual supports
WHAT PROBLEMS AND SYMPTOMS HAS THE PATIENT BEEN EXPERIENCING
THAT PROMPTED THE REQUEST FOR THIS EVALUATION NOW? Please describe
in detail -
What are the key questions you want the Consult Team to answer? :
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UMass ID/MH Evaluation Team Referral Form and Intake Procedure
MEDICATIONS CURRENT AS OF: (PLEASE LIST DATE):
MEDICATION (NAME)
DOSE (AMT)
FREQUENCY
Current Residential Placement:
_____Group residence
_____Group respite
_____Supported living
_____Foster care/Individual supports
_____with Family
_____independent/< 6 hours support
_____facility
_____Residential School
Please briefly describe residential arrangements (How many people live with the
patient? How many caregivers etc.)
Vocational or Educational Placement:
____Sheltered workshop
____Vocational with job coaching
____Employed with part-time supervision, support
____Independently employed
____Day habilitation
____School – Regular
____Other list or describe including School Collaborative
Please briefly describe day activity, work or school setting and schedule:
History of Residential Settings/School and Work Placements
DATE
Facility/home/school etc
Events/responses
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UMass ID/MH Evaluation Team Referral Form and Intake Procedure
DSM-IV Diagnoses from outpatient providers prior to the referral (Please mark X
next to ALL that apply – many people have multiple diagnoses):
Axis I
____Major Depressive Disorder
____Depressive Disorder nos
____Bipolar Disorder – manic
____Bipolar Disorder – mixed
____Bipolar Disorder – depressed
____Bipolar disorder nos
____Generalized Anxiety Disorder
____Anxiety Disorder nos Panic
____Obsessive Compulsive Disorder
____Anxiety Disorder nos Generalized
____Anxiety Disorder nos OCD
____PTSD
____Schizoaffective Disorder
____Schizophrenia
____Psychotic Disorder NOS
____Mental Disorder due to medical list
____Autistic Disorder
____Asperger’s syndrome
____Pervasive Developmental Disorder nos
Other - list
Axis II
____Borderline intellectual fx
____Mild ID
____Borderline Personality Disorder
____Other Personality Disorder list
____Moderate ID
____Severe/profound ID
Axis III Medical Diagnoses - Please list all current medical diagnoses
Axis IV Recent Stressful Life Events : PLASE FILL OUT THE RECENT STRESSORS
QUESTIONNAIRE
DRUG Allergies:
Other Allergies:
Alcohol Use:
Drug Use:
__Yes __ No If yes describe use:
__Yes __ No If yes describe use:
Please comment on the following for the past month – state if behavior represents
a departure from usual, baseline behavior reflecting the person’s optimal
functioning:
1. Mood:
2. Appetite / Weight:
3. Sleeping:
4. Energy level:
5. Motor behavior (looking slower than usual, or pacing and over active):
6. Thinking and concentration:
7. Performance at school, day program or work:
8. Repetitive behaviors or movements:
9. Assaults, SIB or any other disruptive behaviors:
10. Changes in fluid intake:
11. Changes in bowel or bladder habits:
12. Recent episodes of any illness – please describe:
13. Other symptoms or behaviors:
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UMass ID/MH Evaluation Team Referral Form and Intake Procedure
Please Describe the Following for the Patient
A. When he or she is doing well and at his or her best
B. Over the past month or since he or she has been developing increased problems
requiring this referral:
ADLs: (what is this person’s baseline – their best, what is the person doing now?)
Baseline or Best:
Recent:
Hearing, vision, mobility: (Please note any problems in vision, hearing, or walking at
baseline, and now)
Baseline or Best:
Recent:
Communication: (Does this person use words, full sentences or just phrases, is he pr
she hard to understand, is English his or her first language, are alternative forms of
communication helpful etc.)
Baseline or Best:
Recent:
Pain Issues: (How do we know if this person is in pain, will he or she be able to
describe it, are there any recent complaints of pain)
Have there been any recent suspicions of pain or physical distress?
PSYCHIATRIC TREATMENT HISTORY
Psychiatric hospitalizations
DATE
FACILITY
WHAT HAPPENED?
Outpatient Psychiatric care
History of Medication Treatment (attach any summaries already assembled)
History of other psychiatric care, therapy etc.
PYCHOLOGICAL & BEHAVIORAL PROFILE
Self-Injurious Behaviors (please describe):
Suicidal Risk issues (please describe any past suicide attempts gestures, threats etc.):
Aggression/ Homicide Risk (please describe):
Other challenging behaviors:
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UMass ID/MH Evaluation Team Referral Form and Intake Procedure
Name all the situations and things associated with fewer problem behaviors:
Name all the situations and things associated with more negative target behaviors (new
staff, staff who are too strict, task demands that are too hard, any task demands, when
it’s noisy, in the morning, at night etc.:
Things that help prevent agitated behaviors:
Interventions that help restore calm:
Can you tell when he or she is going to have a problem? (Are there “early warning signs
like changes in facial expression, pacing etc.?)
Describe everything you can about staff persons who the patient likes best and is least
likely to have a problem with, and who the patient is most likely to be successful with i.e.
staff person is soft spoken, male or female?, very strict, easy going, lets the patient
make choices, seems less afraid, etc. :
What are some simple things this person would generally find reinforcing
rewarding?(Even if they are not working right now, what has worked?)
Level of Function / IQ Testing (can have up to three of these past IQ tests)
Date Test Name
FSIQ
VIQ
PIQ
WAIS-R
WAIS
Other – list
PSYCHOSOCIAL & DEVELOPMENTAL HISTORY
Birth and development – Please note of there is a known cause of ID
Educational –
Specific Family h/o MH/ID, medical or neurological problems –
PLEASE FILL OUT THE RECENT STRESSFUL EVENTS QUESTIONAIRRE
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