________________
Client Name
BALTIMORE CAPITATION PROJECT REFERRAL FORM
SEND COMPLETED REFERRALS:
To:
Alicia Torres
Fax:
(410) 837-2672
Phone:
(410) 837-2647
BMHS Notes:
PLEASE NOTE: All questions must be completed in order
for the referral to be considered and all
supporting documentation must be attached.
Date:
Received:___________
Waiting:____________
Referred:___________
_____CA
_____CC
___________________
___________________
___________________
___________________
Client Name:
Referral Source: Name: _______________________________
Facility/Agency: __________________________
Phone Number: ___________________________
FAX Number: _________________________
Reason for referral: (If state hospital, please state what has kept the client in the hospital)
DOB:
SS#:
Gender:
Male
Female
Last Known Address & Phone in Community:
Planned address & phone at time of discharge:
Other contact name, address & phone:
Income Source:
Insurance Coverage:
SSI
SSDI
Pending
Medical Assistance
VA Benefits
1
None
Medicare
None
Other ___________
Private
Other_____
________________
Client Name
Diagnosis:
AXIS I:
___________________
AXIS II:
___________________
AXIS III:
____________________
____________________
(Please list all medical conditions)
_________________________________________________________
_________________________________________________________
_________________________________________________________
Medications: (Somatic and Psychiatric)
Active Medical Problems Requiring Ongoing Medical Attention:
Current Community Somatic Care Provider:
Name: ________________________
Location: ______________________
Date of Last Visit: _______________
Substance Abuse: (Check)
Heroin: None Past Present
Frequency of use_____ How used______
Cocaine:
None
Past
Present
Frequency of use _____ How used______
Alcohol:
None
Past
Present
Frequency of use_____ How used______
Marijuana:
None
Other: ________
Past
None
Present Frequency of use_____ How used______
Past
Present Frequency of use______ How used_____
2
________________
Client Name
Legal Issues
Charges Pending
Conditional Release/NCR
Explain all legal issues checked above:
(check)
On Probation/Parole
Past Incarceration
None
Medical Hospitalizations and Dates within the last two years:
Psychiatric Hospitalizations (state, private, and general hospitals) and Dates within
last two years (see eligibility criteria):
Facility
_________________________________
_________________________________
_________________________________
_________________________________
Dates
__________
__________
__________
__________
ER Visits for Mental Health Services and Dates within last two years (see eligibility
criteria):
Facility
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Dates
__________
__________
__________
__________
__________
__________
__________
Past Outpatient Psychiatric Treatment:
Mental Status:
(Check all that apply)
Orientation: Person
Place
Time
Mood (what client reports over the last 2 weeks): Happy
Sad
Neutral
Affect: Euphoric/Manic
Mid Range
Dysphoric
Thought Process: Organized/Linear
Disorganized
Illogical
Loose Assoc./Flight of Ideas
Thought Content: Thoughts Focused On __________________________
3
________________
Client Name
Psychotic Symptoms: Hallucinations: YES NO If yes, type:______________________
Delusions:_(describe)_________________________________________________
Suicidal Thoughts: Yes No
Plan: Yes NO
History of: Yes No
Homicidal Thoughts: Yes No
Plan: Yes NO
History of: Yes No
Insight: Poor
Fair
Good
Judgment: Poor
Fair
Good
Short Term Memory: Intact
Impaired
Long Term Memory : Intact
Impaired
Since the individual may refuse participation in the program, or may not be accepted
for the program, an alternative community service plan needs to be developed.
Please describe the plan for community services other than Capitation.
To be completed by the treating physician:
Based on my observations and treatment of _______________________, it is my
assessment that the individual has the capacity to understand the nature of the program and
has the capacity to voluntarily provide informed consent to participate in the program, or
has a guardian of person who can provide informed consent. The individual being referred
is aware that he/she will be assigned to either Chesapeake Connections at the North
Baltimore Center or Creative Alternatives at Bayview Medical Center.
________________________________
Name of Physician-Please Print
________________________________
Signature of Physician
________________
Date
Release of Information Authorization:
I, _________________________ (client name), give permission for Baltimore Mental
Health Systems, Inc. To release medical records about my care to one or both of the
following programs for the purpose of referring me for mental health care:
Creative Alternatives at Johns Hopkins Bayview Health System
Chesapeake Connections at The North Baltimore Center
Signed, _________________________________ (signature of client)
Date: _________________________
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