MHSS Online Referral Form Please enable JavaScript in your browser to complete this form. - Step 1 of 2Date of Referral *Name *Age *Gender *Please SelectMALEFEMALEDate of Birth *Phone Number *Current MCO (Primary Insurance) *AetnaAnthemOptimaVA PremierMedicaid # *Annual Medicaid Renewal Date *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRegion *Please selectRegion 4 (Richmond)Region 4 (Prince Edward) Region 5 (Tidewater)Referral Source *Referral Source Phone Number *Referral Source Email *Referral Source Fax NumberIs Referral currently receiving Case Management Services? *NoYesName and Phone Number of Case Management Services provider (if applicable):NextURBAN 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) *AgencySelfN/AMENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2a.) Schizophrenia or other Psychotic DisorderMajor Depressive Disorder Bipolar I or Bipolar IIMENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2b.)Requires training in functional skills and appropriate behavior related to health and safetyRequires training in activities of daily living; and use of community resourcesRequires assistance with medication management and/or adhering to a prescribed regimen of medicationAssistance with monitoring health, nutrition and physical conditionRequires training in acquiring basic living skills such as symptom managementRequires training in adherence to psychiatric and medication treatment plansRequires training with developing and the appropriate use of social skills and personal support systemRequires assistance with personal hygiene, food preparation and/or managementMENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2c.) Psychiatric HospitalizationCommunity Stabilization, 23-Hour Crisis Stabilization, or Residential Crisis Stabilization Unit ServicesIntensive 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 illnessMENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2d.)Anti-Psychotic Psychiatric MedicationMood Stabilizing Psychiatric MedicationAnti-Depressant Psychiatric MedicationPsychiatric Medication is contraindicatingMENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (3. – ONLY If Referral is 20 years old or younger)In an independent living situationActively transitioning into an independent living situationNot living with parent(s)/guardian(s) or in supervised settingIs providing his/her own financial supportPlease 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 Upload12345678910Add file 1 Click or drag a file to this area to upload. Add file 2 Click or drag a file to this area to upload. Add file 3 Click or drag a file to this area to upload. Add file 4 Click or drag a file to this area to upload. Add file 5 Click or drag a file to this area to upload. Add file 6 Click or drag a file to this area to upload. Add file 7 Click or drag a file to this area to upload. Add file 8 Click or drag a file to this area to upload. Add file 9 Click or drag a file to this area to upload. Add file 10 Click or drag a file to this area to upload. PreviousPhone Submit Application