Intensive Services Referral Form -- Adults
Check One:
Adult IOP
Referring Clinician:
Clinician Phone:
Referring Agency:
Referral Date:
Consumer Name:
Consumer ID:
D.O.B
Consumer Address:
New Approval
Re-approval
Dates of current authorization period:
to
*Please note that approvals will be granted for the lesser of 6 months or the remaining time until reauthorization*
1. Current Diagnoses:
2. Most Recent LOCUS Score:
LOCUS
LevelDate:
3. Describe services this individual is currently receiving:
4. Describe current symptoms:
5. Describe treatments tried in the past, dates, outcomes and history of psychiatric hospitalization and
contact with the legal system (please be as specific as possible)*:
7. Describe need for program/service applied for within the framework of recovery:
8. Over time, what is the planned step-down process for this individual to a lower level of care?
* For 180-reviews please answer this question for the last 180 days only. Do not repeat information submitted in
previous referrals for this consumer.
The individual experiences significant functional impairments due to mental illness as
demonstrated by the following conditions:
Significant difficulty in consistently performing the range of practical daily living tasks required for basic
functioning at home and/or in the community as evidenced by consistent difficulty with the following:
caring for personal business affairs or budgeting
obtaining medical, legal or housing services
recognizing and avoiding common dangers or hazards to self and possessions
meeting nutritional needs of self/family
maintaining personal hygiene or washing clothes
childcare tasks and responsibilities
Persistent or recurrent difficulty performing age-appropriate daily living tasks except with significant
support or assistance from others such as friends, family or relatives
Significant difficulty maintaining important and/or supportive relationships with others
Significant difficulty maintaining a safe living situation (e.g. excessive hoarding; consistently unsanitary
conditions due to uncollected garbage, food scraps and other waste material)
The individual experiences continuous high service needs due to mental illness as demonstrated
by:
Moderate to high use of psychiatric hospitals (e.g. In the past year: two or more admissions of more than
72 hours’ duration, or thirty or more total days, or a single stay of 21 or more days)
Persistent, recurrent, or severe major symptoms
Co-occurring substance use disorder of significant duration (greater than six months)
Recent and/or recurrent criminal justice involvement
Significant difficulty meeting basic survival needs, currently residing in substandard housing, or homeless
At imminent risk of becoming homeless ( repeated evictions and/or currently on eviction notice)
Residing in a supervised community residence and clinically assessed to be able to live in a more
independent living situation if intensive services are provided
Requiring a residential placement if more intensive services are not available
History of: medication non-adherence and/or treatment non-compliance
Consumer Name:
Consumer Number:
* For 180-reviews please answer this question for the last 180 days only. Do not repeat information submitted in
previous referrals for this consumer.
By signing this form I am agreeing that I would like to receive intensive services as my
clinician has discussed with me.
Consumer Signature: _____________________________________________Date:_________________
Guardian Signature: _____________________________________________Date:__________________
(Required for consumers who have legal guardians)
Clinician Signature: _______________________________________________Date:_________________
Supervisor Signature: ____________________________________________Date:__________________
Consumer signature is requested at initial referral only.
Consumer Name:
Consumer Number: