Pm Form 3.3.1 - Adhs/dbhs Referral For Behavioral Health Services Page 2
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2III. Information to Be Completed by Network Provider/RBHA
Health Plan Name: _____________________
Individual Name: ______________________
AHCCCS ID#: _________________________
Individual DOB: ______________________
Date / Time Received ___________________
Outreach Attempts:
1) Date/Time: _________________
Outcome:
Comments:
______
______________
_____________________
2) Date/Time: _________________
_____________
_______
Outcome:
_____________________
Comments:
Comments: _____________
_______
3) Date/Time: _________________
Outcome:
_____________________
Unable to Contact Person Being Referred
Number of outreach attempts: ____
Type of Outreach and Engagement conducted (Check all that apply)
Phone Call
Number of calls ____
Face to face visit attempt
Number of attempts ____
If unsuccessful, state reason why (check all that apply)
No answer to phone call(s)
Message(s) left with no response
Telephone disconnected
Person being referred already enrolled in behavioral health services
Name and contact information of the Provider that will assume primary responsible for the person’s behavioral health
care:_______________________________________________________________________
______________________________
Person being referred refuses behavioral health services
Referral source notified of unsuccessful contact. If this box is checked, list alternate contact information obtained: _______________
**IF UNABLE TO CONTACT - STOP HERE**
Type of Appointment:
Immediate
Urgent
Routine
Available Intake Appointment Offered; specify date, time, place _________
__________________________________________
Action Taken:
______________
____________________
___
__
______
_____________
Scheduled Intake Appointment; specify date, time, place
Not Referred for Appointment; specify why _ ____________________________________________________________________
___________________________________________
________________________________________
Other Disposition; explain
If applicable, name and contact information of the provider that will assume primary responsibility for the person’s behavioral health care:
___________________________________________________________________________________________________
IV. Outcome
Intake appointment kept?
Yes
No If no, why? Check all that apply:
Rescheduled by provider
Rescheduled by person being referred
Cancelled without rescheduling by person being referred
____________________________
Person being referred was a “No show” If no show, number of outreach and engagement efforts
_________________________
Was the Assessment done on same day as Intake?
Yes
No
If no, date assessment scheduled for:
****Please return form to referral source with “Action Taken” Section completed.****
Last revision: 08/21/2009
2
Effective date: 07/01/2009
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Parent category: Medical