Alliance Health



Care Review Referral FormToday’s Date: Enter a dateCounty: Choose an itemType of Care Review Referral: ?Youth ? AdultUrgency of Request: ?ASAP ?Within 30 daysReason for Care Review: ? Technical assistance ? Follow up from previous Care Review ? Service coordination ? Exhaustion of resources known to team ? Other: (Specify)For Durham Homeless referrals only: Client ID# (Type #) VI-SPDAT# (Type #)Participant Information Participant Name: First Name Last Name Gender: ?Male ? Female DOB: Enter a date Age: Enter Age Insurance: Choose an item Participant/Guardian address: Phone: ( ) - Street Address City , NC Zip Code Legal Guardian Name: ? N/A First Name Last Name Phone: ( ) - Relationship: ?Parent ? Relative ? DSS ? Other: (Specify) Are there any accommodations or factors to consider when scheduling the Care Review? ? None ? Non-English Speaker* ? ADA* ? Time/Day considerations (including after school) ? Other Please specify accommodation: *If participant needs an interpreter, referral source is responsible for securing an interpreterReferral Information Referral Source: First Name Last Name Title: Agency/Provider: Email address: Phone: ( ) - Needs Expressed by the ParticipantPlease complete this section with the participant. This section will inform who attends the Care Review as well as help us understand the priorities of the participant.Discuss the participant’s strengths, goals, and interests: How are you (the participant) hoping the Care Review process can help you? What needs would you like addressed in the following areas: Housing: ? Yes ? NoTransportation: ? Yes ? NoEducational: ? Yes ? NoVocational: ? Yes ? NoFinancial: ? Yes ? NoLegal: ? Yes ? NoEmotional/Psychological: ? Yes ? NoHealth (including ability to afford and obtain prescribed medications): ? Yes ? NoSocial/Recreational/Spiritual: ? Yes ? No What, if any, additional concerns do you have? Please check any supports or resources you currently have: ? Enrolled in school/Day treatment/Homebound ? Full-time employment ? Part-time employment ? Vocational Rehab ? Behavioral Health Therapy ? Medication Management ? Spiritual ? AA/NA or similar recovery program ? Other group or program regularly attending ? Reliable Transportation ? IDD Services ? Care Coordination ? Other interpersonal support or mentor ? SSI/SSDI ? Work First ? Unemployment benefits ? VA benefits ? SNAP ? WIC ? IEP ? 504 Plan ? Housing Assistance ? Other (Specify) Please list any natural supports (family, spiritual, friends, mentors, groups or activities):Additional Information Is the participant connected to a mental health provider? ? Yes ? No Please list the clinical home: Has the participant been admitted to the hospital for psychiatric care in the past 3 months? ? Yes ? No Has the participant been admitted to a Crisis Facility in the past 3 months? ? Yes ? No Which facility? Does the participant have a mental health diagnosis? ? Yes ? No If so, what type? ? MH ? IDD ? SA/SUD Is the participant connected to a primary care physician? ? Yes ? No Please list the medical home: Has the participant had a preventive medical screening in the past 15 months from a primary care physician? ? Yes ? No If participant is a youth, do they have a Child and Family Team? ? Yes ? No ? N/A Date of last CFT meeting: Click here to enter a date If participant is an adult, do they have a treatment or support team that meets regularly? ? Yes ? No ? N/A Date of last meeting: Click here to enter a date Who attends the CFT or other treatment team meetings (list names and affiliation, provider is responsible for inviting specific members to the Care Review meeting): ? N/A If applicable, please provide the name and contact info of the juvenile court counselor: First Name Last Name Email address: Phone: ( ) - If applicable, please provide the name and contact info of the adult probation officer: First Name Last Name Email address: Phone: ( ) - Once complete, you may submit the form to the appropriate email address:Durham County: DurhamCareReview@Wake County: WakeCareReview@Cumberland County: CumberlandCareReview@Johnston County: JReview@ ................
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