Therapeutic Behavioral Services Referral Form - Department Of Behavioral Health

Download a blank fillable Therapeutic Behavioral Services Referral Form - Department Of Behavioral Health in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Therapeutic Behavioral Services Referral Form - Department Of Behavioral Health with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

THERAPEUTIC BEHAVIORAL SERVICES
REFERRAL
Client Name _____________________________Medi-Cal No._____________________ Date____________________
Client Date of Birth__/__/___
Gender
Male
Female
Child’s Current Placement (or Family) Address________________________________________________________
Parent/Caretaker Name_________________________________ Parent/Caretaker Phone_____________________
Family Home
Residential Placement (RCL Level ___)
Juvenile Hall
Other (Specify_______________)
Referring Party__________________________________ Title___________________ Phone_____________________
Is child/youth a full scope Medi-Cal beneficiary under age 21?
Yes
No
Please list client’s current Axis I diagnosis: ________________________________________________________________________
Check here if Mental Health Assessment was completed in past year (Please attach or indicate any recent data; it is not necessary
to repeat information from prior assessment)
Which of the following conditions have been met?
(Must check at least one.)
At least one emergency psychiatric hospitalization related to current presenting disability within the past 24 months
At risk of psychiatric hospitalization due to presenting disability
Currently placed in a level 12 or above group home for mental health needs
Being considered for placement in a level 12 or above group home through San Bernardino County
Previously received Therapeutic Behavioral Services (TBS) through San Bernardino County
Which is highly likely to occur without additional support? (Must check at least one.)
Child/youth may need higher level of residential care or acute care
Child/youth may not successfully transition to a lower level of care
What mental health services is the client currently receiving?
None
List other involved agencies.
Agency
Contact Person
Phone Number
What are the specific problem behaviors jeopardizing current living situation?
Describe alternative approaches that have been tried:
Are there any specific needs with regard to the TBS coach’s language, culture, or gender?
***SIGNED CONSENTS MUST ACCOMPANY REFERRAL.
FAX REFERRAL PACKET TO DBH/CCICMS TBS-TRAC UNIT at 909-387-7611
(For Departmental Use Only)
Eligible
Ineligible (Comments____________________________________________________________________________)
Signature____________________________________ Name Printed_________________________________ Date______________
Therapeutic Behavioral Services
NAME:
Referral Form
SAN BERNARDINO COUNTY
CHART NO.:
DEPARTMENT OF BEHAVIORAL HEALTH
Confidential Patient Information
DOB:
See W&I Code 5328
PROGRAM:
8-2011/TBS/CCICMS/dt White

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Ma-5 - Claim Form - Department Of Public Health And Human Services Form Ma-5 - Claim Form - Department Of Public Health And Human Services Legal
Form 3949 A - Information Referral Form - Department Of Treasury(2005) Form 3949 A - Information Referral Form - Department Of Treasury(2005) Financial
Attachment 20a - Consent For Therapeutic Behavioral Services - Riverside County Department Of Mental Health Attachment 20a - Consent For Therapeutic Behavioral Services - Riverside County Department Of Mental Health Legal
Nyc Nurse-family Partnership Referral Form - Department Of Health And Mental Hygiene Nyc Nurse-family Partnership Referral Form - Department Of Health And Mental Hygiene Legal
Montana State Case Registry And Vital Statistics Reporting Form Department Of Public Health And Human Services Montana State Case Registry And Vital Statistics Reporting Form Department Of Public Health And Human Services Legal
Illinois' Immunization Registry Opt Out Of Registry Form - Department Of Public Health Illinois' Immunization Registry Opt Out Of Registry Form - Department Of Public Health Legal
Form Dmas-355 - Virginia Treatment Referral Information - Department Of Medical Assistance Services Form Dmas-355 - Virginia Treatment Referral Information - Department Of Medical Assistance Services Medical
Form F-01164 - Forwardhealth Sterilization Consent Form - Department Of Health Services - 2006 Form F-01164 - Forwardhealth Sterilization Consent Form - Department Of Health Services - 2006 Legal
Form Dmh 5-72-01 - Examination And Recommendation For Ivc Form - Department Of Health And Human Services - North Carolina Form Dmh 5-72-01 - Examination And Recommendation For Ivc Form - Department Of Health And Human Services - North Carolina Legal
Form Ioci 12-234 - Emergency Medical Services (ems) Systems Reactivation Request Form - Illinois Department Of Public Health Form Ioci 12-234 - Emergency Medical Services (ems) Systems Reactivation Request Form - Illinois Department Of Public Health Medical

Related Categories

Parent category: Legal
Download
Go