CRISIS STABILIZATION REFERRAL SERVICE FORM MHSS/IIH Referral Form Referral Form Download (Word) Date of Referral * MM DD YYYY Referral Source * Referral Source Phone Number * (###) ### #### Individual Information Consumer Name * First Name Last Name Medicaid Number * Insurance Provider * Aetna Anthem Magellan Molina Sentara United Healthcare Not Insured Other Date of Birth * MM DD YYYY Gender * Male Female Social Security Number * Parent/Guardian Name If applicable First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Email Type of Housing * i.e. Homeless, Shelter, Group Home, etc. PCP Name/Clinic PCP/Clinic Phone Number (###) ### #### Reason for Referral/Presenting Problem * Currently in Crisis * Yes No If Yes, Please Explain Current/Presenting Problem * Presenting needs/situation including psychiatric and medical problems, current medications, and history of medical care (Check all that Apply) Easily Agitated Trauma Destructive Social Phobias Physically Aggressive Having Trouble Keeping Employment Withdrawn Thoughts of Suicide Depressed Homicidal Ideations Mania/Hypomania Eating Problems Sleeping Problems Physical Abuse Issues Stealing Trouble with Law Alcohol/Drug Use Fire Setting Verbally Aggressive Anger Outbursts Sexual Abuse Issues Housing Issues/Homelessness Medication Compliance Self-Mutiliation Irritable Lack of Food/Resources Additional Comments Have Mental Health Services Been Received Before * Yes No If Yes, Describe Eligibility and Documentation At least two of the following criteria must be met to qualify for services I. In order to receive crisis stabilization services, the individual must meet at least one of the following criteria: Is the individual experiencing marked reduction in psychiatric, adaptive, or behavioral functioning? * Yes No Is the individual experiencing extreme increase in emotional distress? * Yes No Is the individual in need of continuous intervention to maintain stability? * Yes No Is the individual causing harm to self or others? * Yes No II. The individual must be at risk of at least one of the following: Psychiatric Hospitalization * Yes No Emergency ICF/IID Placement * Yes No Disruption of community status (living arrangement, day placement, or school) * Yes No Causing harm to self or others * Yes No Thank you!
