Adult Behavioral Health Screening Form for Assessment and Treatment as Medically Necessary
MEMBER INFO
Patient Name: ___________________________________________________________________ Date of Birth: ____/_____/_____
M
F
Medi-Cal # (CIN): _________________ Current Eligibility: ___________________ Language/cultural requirements: _________________
Address: ________________________________ City: _________________________ Zip: __________
Phone: (_____) ____________________
Caregiver/Guardian: ________________________________________________________________
Phone: (_____) ____________________
Behavioral Health Diagnosis
1) _______________________________
2) _______________________________ 3) ___________________________
Is provisional diagnosis/diagnosis an included diagnosis for MHP services (see back)
Yes
No
Unsure
Documents Included:
Required consent completed
MD notes
H&P
Assessment
Other: ________________________
Primary Care Provider ________________________________________________________________
Phone: (_____) ____________________
List A
List B
List C
(check all that apply)
(Check all that apply)
Drug use or
Persistent symptoms & impairments after 2
2+ psychiatric hospitalizations within 12 months
alcohol
recent medication trials
Paranoia, delusions, hallucinations not due to
addiction
Multiple co-morbid health and mental
substance use or medical condition
and/or failed SBI
health conditions
3+ criminal justice mental health episodes in past year
(screening &
Behavior problems (aggressive/self-
Suicidal/Homicidal preoccupation or behavior in past
brief intervention
destructive/assaultive/extreme isolation)
year
at primary care
)
2+ ED visits or 911 calls in past year
Transitional Age Youth over 18 with acute psychotic
*Please include any
episode not due to substance use
toxicology screens or
Bipolar disorder or manic episode
labs as applicable
Significant functional impairment due to an included
Trauma/recent loss/significant life stressors
mental health diagnosis (e.g. WHODAS score, other
(e.g. homelessness, domestic violence)
identified measures)
Mild-moderate depression/anxiety
Self-injurious behaviors
Foster care non-minor dependent
Referral Algorithm
1
Remains in PCP care with Beacon consult or therapy only
1-2 in List A and none in List B
3 or more in list A and none in list B OR
2
Refer to Beacon Health Strategies(eFax (866) 422-3413)
Diagnosis excluded from county MHP
1 or more in list B + included diagnosis with
3
Refer to County Mental Health Plan for assessment
significant impairment (see next page for list)
4
Refer to County Alcohol & Drug Program
Any in list C
Referring Provider Name: __________________________________________________
Phone: (_____) ________________
Referring/Treating Provider Type
PCP
MFT/LCSW
ARNP
Psychiatrist
Other ______________________________________
Requested service
Outpatient therapy
Medication management
Assessment for Specialty Mental Health Services
Pertinent Current/Past Information:
Current symptoms and impairments: __________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Brief Patient history: ___________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
For Receiving Clinician Use ONLY
Assigned Case Manager/MD/Therapist Name: _____________________________________ Phone: (_____) __________________________
Date communicated assessment outcome with referral source: _____________________________________________________________