Community Stabilization Online Referral Form

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Date of Referral

Name of Individual being Referred

Age

Gender

Identifies As

Date of Birth

Parent/Legal Guardian/Authorized Representative (if applicable)

Phone Number (of Referral or Parent/Leg. Guard./Auth. Rep.)

Email (of Referral or Parent/Leg. Guard./Auth. Rep.)

Confirm Email

Current MCO (Primary Insurance)

Aetna
Anthem
Magellan Healthcare
Sentara

Medicaid #

Address

Address Line 1

City

State

Zip Code

Region

Referral Source

Referral Source Phone Number

Referral Source Email

Referral Source Fax Number

Is Referral currently receiving Case Management Services?

Name and Phone Number of Case Management Services provider (if applicable):

URBAN LEARNING AND LEADERSHIP CENTER FAMILY SERVICES INTENSIVE IN-HOME COUNSELING & MENTAL HEALTH SKILL-BUILDING SERVICES Screening/Admission Form MENTAL HEALTH SKILL-BUILDING SERVICES (ages 18+)

This question is for ULLCFS Staff Use Only (all Others may select N/A)

Agency
Self
N/A

Individuals must meet Criterion #1 and #2 to receive COMMUNITY STABILIZATION SERVICES:

1. Documentation indicates evidence that the individual currently meets criteria for a primary diagnosis consistent with the most recent version of the International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis that correlates with the Diagnostic and Statistical Manual; and
2. The individual has demonstrated a level of acuity indicating that they are at risk for crisis-cycling or dangerous decompensation in functioning and additional support in the form of community stabilization is required to prevent an acute inpatient admission; and

(Prior to Admission) Individuals meeting either Criterion 3B-I. or 3B-II. above must also meet the following Additional Criterion:

3B-III(a). The service that the individual needs and is recommended by a professional listed in item i. above or a professional coordinating the discharge plan from services listed in item ii. above is not currently available for immediate access;
3B-III(b). A clinically appropriate and specific behavioral health service provider referral(s) has been identified and a plan for the timeline of transition from Community Stabilization to that provider has been established and documented. If the timeline for this transition exceeds 2 weeks, the Community Stabilization provider has documented communications with additional, specific service providers to support alternative service options or potentially faster access to the recommended service type.

Please provide a brief description of the behaviors being exhibited by Referral (reason for service request)

Please Upload any Documents such as

List of Medications • Psychiatric Evaluations • Physical Examinations • Psychological Evaluations • Discharge Documentation from Medical/Psychiatric Facilities • Independent Clinical Assessments (via VICAP) • Etc...

Number of Files to Upload

Add file 1

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