Required Information for: Community Based Case Management ...
Required Information for: Community Based Case Management (CBCM), Expanded Adult Residential Care Home (E-ARCH), Hale Imua, Intensive Out Patient Hospital (IOH), KFit, Specialized Residential Services Program (SRSP), Day Treatment and Aftercare, Therapeutic Living Program (TLP).
All documents must be the most current version | |
|CONSUMER NAME |
|Submit the following for all services listed above: |
| |Psychiatric Evaluation (completed within the last 12 months) |
| |Psychosocial Assessment (if separate from the psychiatric evaluation) |
| |Medical/Nursing Assessment (if available) |
| |Medication Sheet (if available) |
| |Risk Assessment: Identify any known areas that may (or has in the past) present(ed) a risk for harm to self or others |
| |LOCUS |
| |Substance Abuse Assessment (if available) |
|Additionally, submit the following for: SRSP, E-ARCH, TLP, CBCM, Hale Imua & KFit |
| |Special diet requirements (if any) |
| |PPD |
| |Medical History and Physical (completed within one year of referral date and includes Rubella Titer/proof of immunization)|
| |This line item is NOT needed for Specialized Residential or TLP. |
|Please provide a brief narrative of the reason for referral, precipitating events and goals for this referral: |
| |
|Please complete if referring to Specialized Residential Treatment: What is the current discharge plan upon completion of the |
|program? |
| |
| |
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