Adult
ALLEGANY COUNTY MENTAL HEALTH CASE MANAGEMENT PROGRAM
Adult Initial Referral and Intake Form
Participant: _____________________________ Phone#: _______________ DOB:___________
Address: ______________________________________________________________________
SS#:___________________ Sex: ___ Marital Status: ___
Referral Date: ______________ Referring Agency: ____________________________________
Contact Person: __________________________________ Contact#: ______________________
Reason for Referral: _____________________________________________________________
______________________________________________________________________________
Medicaid #: __________________________
If client does not have Medicaid they must meet the following criteria:
_____ Currently being discharged from an inpatient psychiatric facility or
____ To prevent eminent hospitalization
And
In addition to previous uninsured criteria clients must meet the following conditions:
____ Must have an income of no more than 200% of the federal poverty level
____ Must have an urgent need
Diagnosis: To be eligible for services clients must have one of the following diagnoses, please check off
the diagnostic code for as many diagnoses as apply:
Schizophreniform Disorder
295.40
Schizoaffective Disorder
295.70
Schizophrenia
295.90
Other Schizophrenia/Psychotic
298.8
Unspecified Schizophrenia/Psychotic
298.9
Delusional Disorder
297.1
Major Depression
296.33
296.34
Bipolar I Disorder
296.40
296.43
296.54
296.7
Unspecified Bipolar
296.80
Bipolar II
296.89
Personality Disorder
Type:
Type:
301.22 Schizotypal
Bipolar
296.44
Depressive
296.53
301.83 Borderline
Provider Making Diagnosis __________________________ Date of Diagnosis _____________
Revised: Jan. 2015
Page 1 of 3 pages
Adult
One of the following criteria must be met for services:
____ Are in , are at risk of, or need continued community treatment to prevent inpatient psychiatric
Treatment;
____
At risk of, or need continued community treatment to prevent being homeless; or
____
At risk of incarceration or will be released from a detention center or prison.
The specific diagnostic criteria may be waived for the following two conditions:
____
An individual committed as not criminally responsible who is conditionally released from a
Mental Hygiene Administration facility; or
____
An individual in a Mental Hygiene Administration facility or a Mental Hygiene Administration
Funded inpatient psychiatric hospital who required community services. This excludes individuals
eligible for Developmental Disabilities Administration’s residential services.
One of the following criteria must be met for services:
____
Not linked to mental health and medical services;
____
Lacks basic supports for shelter, food, and income;
____
Transitioning from one level of care to another level of care; or
____
Needs to maintain community-based treatment and services.
One of the following criteria must be met for General Services:
____
Has been discharged from a state mental hospital in the past 90 days.
____
Has been discharged from a mental health residential treatment facility within the last 12 months.
____
Has had more than one admission to a crisis stabilization unit(CSU), short-term residential
facility(SRT), inpatient psychiatric unit, or any combination of these facilities within the last 12
months;
____
Is experiencing long-term and/or increasing acute episodes of mental impairment that may put him or
her at risk of requiring intensive level of services.
One of the following criteria must be met for Intensive Services (Medicaid clients only):
____
Has been discharged from a state mental hospital in the past 30 days.
____
Has demonstrated a need for increased services from the General Level.
____
Has resided in a state mental hospital for at least 2 months in the past 24 months:
____
Resides in the community and has had two or more admissions to a psychiatric hospital in the past 12
months;
____
Resides in the community and has had five or more admissions to a crisis stabilization unit(CSU),
short-term residential facility(SRT), inpatient psychiatric unit, or any combination of these facilities
within the past 12 months;
Revised: Jan. 2015
Page 2 of 3 pages
Adult
____
Resides in the community and, and due to a serious mental illness, exhibits behaviors or symptoms
that could result in long-term hospitalization if intensive interventions for an extended period of time
or not provided.
____
Has resided in a state mental hospital for at least 6 months in the past 24 months.
Primary Care Provider:  Tri-State CHC  Other _________________________________
In addition to the information above, Consumer has the following urgent needs:
____ Medication Assistance
____ Mental Health Linkages
____ Homeless/At Risk
____ Emergency Shelter ____ Missed MH Appts _____ Food ____ Application for MA
____ Application for Other Entitlements ____ Dual Diagnosis Tx ____ Somatic Care (describe below)
____ Being Discharged from hospital _____ Other: _____________________________________
Additional Comments: (Please provide as much information as possible)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
____________________________________________________________________
Case Management Program Only:
Based on the above information, ____________________________, has been determined eligible for Case
Management Services, ____Yes ____No
Revised: Jan. 2015
Page 3 of 3 pages