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ADMINISTRATIVE OFFICE: 1919 Commerce Drive, Suite 300, Hampton, VA 23666
OFFICE HOURS:Monday-Friday: 9 am to 5 pm
757-224-8017[email protected]

MHSS Online Referral Form

Home MHSS Online Referral Form

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Date of Referral *

Name of Referral *

Age *

Gender *

Identifies As

Date of Birth *

Phone Number (of Referral or Authorized Representative) *

Email (of Referral or Authorized Representative)

Email

Confirm Email

Current MCO (Primary Insurance) *

Aetna
Anthem
Magellan Healthcare
Sentara Community Plans

Medicaid # *

Address *

Address Line 1

City

State

Zip Code

Region *

Referral Source *

Relationship to Referral *

Referral Source Phone Number *

Referral Source Email *

Referral Source Fax Number

Is Referral currently receiving Case Management Services? *

No
Yes

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

MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2a.)

Schizophrenia or other Psychotic Disorder
Major Depressive Disorder
Bipolar I or Bipolar II

MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2b.)

Requires training in functional skills and appropriate behavior related to health and safety
Requires training in activities of daily living; and use of community resources
Requires assistance with medication management and/or adhering to a prescribed regimen of medication
Assistance with monitoring health, nutrition and physical condition
Requires training in acquiring basic living skills such as symptom management
Requires training in adherence to psychiatric and medication treatment plans
Requires training with developing and the appropriate use of social skills and personal support system
Requires assistance with personal hygiene, food preparation and/or management

MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2c.)

Psychiatric Hospitalization
Community Stabilization, 23-Hour Crisis Stabilization, or Residential Crisis Stabilization Unit Services
Intensive Community Treatment (ICT)
Program of Assertive Community Treatment (PACT)
Psychiatric Residential Treatment Facility (RTC Level C)
Temporary Detention Order (TDO)
Evaluation as result of decompensation due to serious mental illness

MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2d.)

Anti-Psychotic Psychiatric Medication
Mood Stabilizing Psychiatric Medication
Anti-Depressant Psychiatric Medication
Psychiatric Medication is contraindicating

MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (3. – ONLY If Referral is 20 years old or younger)

In an independent living situation
Actively transitioning into an independent living situation
Not living with parent(s)/guardian(s) or in supervised setting
Is providing his/her own financial support

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...

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CONTACT US

Administrative Office

1919 Commerce Drive

Suite 300

Hampton, VA 23666

757-224-8017

757-224-8094

[email protected]

Main Office

700 Tech Center Parkway

Suite 200 – #40

Newport News, VA 23606

757-224-8017

757-224-8094

[email protected]

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