REFERRAL FORM for TRANSITION AGE CARE COORDINATOR Must be ages 16-25 Washington County Behavioral Health and Developmental Services Fax: 724-250-4156 Consumer Name:

MA ID #:

Date:

SSN:

Age:

DOB:

Insurance:

Address:

VBH

County

Other:

Phone:

REASON FOR REFERRAL (Please indicate why you believe other services will not meet this individual’s needs):

PERSON MAKING REFERRAL:

1. DIAGNOSES:

AGENCY:

(PLEASE ATTACH A PSYCHIATRIC EVALUATION VERIFYING THE DIAGNOSIS)

Please list diagnoses:

DEVELOPMENTAL DISABILITY INTELLECTUAL DISABILITY (If ID, indicate IQ score) 2. MENTAL HEALTH TREATMENT HISTORY RTF/CRR

Met 302/304 C or Act 147 Criteria.

Inpatient psych hospitalization

Crisis Intervention Services

PLEASE PROVIDE A BRIEF HISTORY OF ALL MENTAL HEALTH SERVICES RECEIVED:

3. OTHER TREATMENT HISTORY

PLEASE DESCRIBE LEVEL OF INVOLVEMENT OR SERVICES RECEIVED

BASE SERVICE UNIT CYS JUVENILE OR ADULT LEGAL INVOLVEMENT DRUG & ALCOHOL OTHER COMMUNITY SUPPORT/SERVICES:

4. RISK FACTORS Suicidal/homicidal ideation

Yes

No

No medical insurance

Yes

No

Previous suicide attempts

Yes

No

Self-injurious behavior

Yes

No

Drug and alcohol use

Yes

No

Lack of family/natural supports

Yes

No

Homelessness

Yes

No

Significant life change

Yes

No

History of trauma

Yes

No

History of legal involvement

Yes

No

Complex physical health needs:

Yes

No

Lack of self-preservation skills:

Yes

No

History of sporadic course of treatment as evidence by: At least 3 missed community mental health appointments in past 6 months Two or more face to face encounters with Crisis or Emergency services in past 2 years Documentation that consumer has not maintained her/his medication regimen Involuntary outpatient commitment. Difficulty engaging in or Resistant to treatment

I WISH TO BE CONSIDERED FOR TRANSITION AGE CARE COORDINATOR.

Consumer’s Signature: ________________________________________________________

Date: _______________

Person completing referral: ____________________________________________________ Date: _______________ Revised 8/17/15