WESTERN MASSACHUSETTS DEPARTMENT OF MENTAL …



Commonwealth of MassachusettsDEPARTMENT OF MENTAL HEALTHDMH Respite Referral Form Site Based: FORMCHECKBOX Mobile: FORMCHECKBOX To:Name: FORMTEXT ?????Respite Program: FORMTEXT ?????From:DMH Contact Name: FORMTEXT ????? Phone: FORMTEXT ????? Address: FORMTEXT ?????E-Mail: FORMTEXT ?????Individual Being Referred:Name: FORMTEXT ????? EMR#: FORMTEXT ?????Phone: FORMTEXT ????? D.O.B.: FORMTEXT ?????Gender: FORMTEXT ?????Home Address: FORMTEXT ?????Current Location: FORMTEXT ?????MassHealth Policy# (If applicable): FORMTEXT ?????Legally Authorized Representative (LAR) (if applicable): FORMTEXT ?????Phone: FORMTEXT ????? Mailing Address: FORMTEXT ?????Name of Prescriber of Psychiatric Medications (if applicable): FORMTEXT ?????Phone: FORMTEXT ?????DMH Case Managed? Yes FORMCHECKBOX No FORMCHECKBOX If “Yes,” Case Manager Name: FORMTEXT ?????Phone: FORMTEXT ?????Enrolled in another DMH Service? Program? Yes FORMCHECKBOX No FORMCHECKBOX If “Yes,” Service Type: FORMTEXT ?????Agency: FORMTEXT ????? Service Type Contact Name: FORMTEXT ????? Phone: FORMTEXT ????? Address: FORMTEXT ?????Application for DMH Continuing Care Services in the CommunityIs Person Currently Approved for DMH Continuing Care Services in the Community?Yes FORMCHECKBOX No FORMCHECKBOX If “No” above, is a Request for DMH Services Pending?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, Date of Application: FORMTEXT ?????Dates and Reason for Referral (choose only one option below):Proposed Start Date: FORMTEXT ?????Projected Discharge Date: FORMTEXT ????? FORMCHECKBOX Step Down from Acute Inpatient Facility FORMCHECKBOX Step Down from DMH Continuing Care Inpatient Facility FORMCHECKBOX Diversion from Emergency Department FORMCHECKBOX Diversion from Continuing Care Inpatient Admission FORMCHECKBOX Transfer from Acute CSU bed FORMCHECKBOX Diversion from Court as a 15a FORMCHECKBOX Step Down From a Correctional Facility (jail/prison) FORMCHECKBOX Other life interrupting need. Please Specify below (e.g., domestic dispute, tenancy issues/eviction, etc.). Comments: FORMTEXT ?????Projected Outcome and Goals of the Respite Stay: FORMTEXT ?????Anticipated Length of Stay (days): FORMTEXT ?????Individual’s Preferences: FORMTEXT ?????Name: FORMTEXT ?????Mental Health and Substance Use Information:1. Statement of Current Situation: FORMTEXT ?????2. Diagnoses (Include psychiatric and medical diagnoses): FORMTEXT ?????3. Mental Status Narrative: FORMTEXT ?????4. Medications (include current medications prescribed for both psychiatric and medical reasons): FORMTEXT ?????5. Substance Use/Abuse Issues (Please include substance(s) used, date of last use, toxicity screen results, and discharge plan if person uses while in the respite program): FORMTEXT ?????6. Current Mental Health and Substance Use Providers (Please include name and contact information) FORMTEXT ?????Risk Behaviors:7. Risks to Self (Include information about current and relevant past self-injurious behaviors, suicidal ideations, suicidal attempts) FORMTEXT ?????8. Risks to Others (Include information about current and relevant past assaultive behaviors ,homicidal and assault ideations) FORMTEXT ?????Name: FORMTEXT ?????Legal Issues:9. Legal Issues (Please include such information as pending charges, upcoming court dates and locations, probation officer contact information, problematic sexual behaviors, past convictions, etc). FORMTEXT ?????10. Is person listed with Sex Offender Registry Board (SORB)?Yes FORMCHECKBOX (Indicate Level: FORMTEXT ????? )No FORMCHECKBOX Medical Information:11. Current Medical Providers (Please include Primary Care Physician (PCP) name and contact information) FORMTEXT ?????12. Current Medical Conditions: FORMTEXT ?????13. Allergies: FORMTEXT ?????Additional Information:14. Is individual able to ambulate without assistance?Yes FORMCHECKBOX No FORMCHECKBOX 15. Who will transport client to program? FORMTEXT ?????16. Is individual arriving with two (2) weeks supply of medications?Yes FORMCHECKBOX No FORMCHECKBOX If “No” above, list date, time, and method of delivery of medications to program: FORMTEXT ?????Information to be shared with DMH:Please send the following to: FORMTEXT ????? FORMCHECKBOX Assessment & Treatment Plan FORMCHECKBOX IAP and Progress Reports FORMCHECKBOX Request to Extend Services Beyond Original Authorization FORMCHECKBOX Termination Summary at Conclusion of Services FORMCHECKBOX Other (specify): FORMTEXT ?????Required DMH Signature__________________________________________________________ _____________________________DMH Director or Designee DateThe Following Section Must Be Completed By the Respite ProgramWas Intake Completed? Yes FORMCHECKBOX No FORMCHECKBOX If Yes, Requested Enrollment Date: FORMTEXT ?????If Intake was NOT completed, please explain by checking one of the reasons below: FORMCHECKBOX Individual declined Respite Services. FORMCHECKBOX Unsuccessful in making contact with individual. FORMCHECKBOX Not Enrolled due to individual poses a significant and present threat to the general safety of Respite Services. FORMCHECKBOX Other (Please explain): FORMTEXT ?????___________________________________________________________ _____________________________Respite Program Manager DateConfidentiality Notice:? Protected Health Information from the Department of Mental HealthImportant Warning:? This message is intended only for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law.? If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, the disclosure, copying or distribution of this information is strictly prohibited.? If you have received this message in error, please notify the sender immediately. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download