Behavioral Health Screening Form To Obtain Behavioral Health Assessment Template
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4Behavioral Health Screening Form to Obtain Behavioral Health Assessment
Please complete and follow algorithm
***If this is an emergency, please call 911
Referral Date: _____________________
REFERRING PROVIDER INFORMATION
Please indicate where the Receiving Clinician should send the disposition of the urgent appointment:
Fax number:
(
)
-
To the attention of:
MEMBER INFORMATION
Patient Name: ______________________________________________________________ Date of Birth: ____/____/____ M F
(Last)
(First)
Medi-Cal # (CIN): _________________ Current Eligibility: ___________________ Language/cultural requirements: ___________________
Address: ________________________________ City: _________________________ Zip: ________ Phone: (_____) ___________________
Caregiver/Guardian: _________________________________________________________________ Phone: (_____) ___________________
Referring Clinician: _________________________________________________________________ Phone: (_____) ___________________
Primary Care Provider ____________________________________Phone: (_____) ______________ Health Plan: ______________________
Behavioral Health Diagnoses (1) __________________________ (2) __________________________ (3) _____________________________
Documents Included with Referral: Required consent completed MD
H&
Other: _________________________
Desired/existing behavioral health clinician/provider/program, if any:___________________________________________________________
List A - check all that apply:
Homelessness
Behavior problems (aggressive/self-destructive/assaultive)
Still symptomatic after 2 standard psychiatric med trials
Paranoid, hearing voices, seeing things, delusional
History of bipolar disorder or manic episode
Excessive emergency room visits or hospitalizations
Excessive truancy or failing school
Significant functional impairment in key roles, (e.g., work, home, self-care)
Substance and/or alcohol addiction and failed Screening and Brief Intervention (SBI)
List B - check all that apply if they occurred within the past 12 months:
>2 psychiatric hospitalizations
>2 incarcerations
Suicidal/homicidal preoccupation or behaviors***
Referral algorithm based on checked boxes:
URGENT 2 or more in list A and one in list B OR 2 or more in list B:
Fax form to DMH Urgent Line for urgent appointment at (562) 863-3971
ROUTINE 3 or more in list A and none in list B OR one in both lists:
Call DMH ACCESS Center for routine referral at (800) 854-7771
Call health plan’s behavioral health network for
HEALTH PLAN REFERRAL 1-2 in list A and none in list B OR only one in list B:
consultation or non-specialty mental health services referral
SUD ONLY Substance and/or alcohol addiction and failed SBI alone:
Call Substance Abuse Prevention & Control at (888) 742-7900
Pertinent Current/Past Information
Current symptoms and impairments: _____________________________________________________________________________________
___________________________________________________________________________________________________________________
Brief MH/SUD history: _______________________________________________________________________________________________
Brief medical history/diagnosis: ________________________________________________________________________________
Current Medication(s) & Dosage: _______________________________________________________________________________________
For Receiving Clinician Use ONLY
Instructions: Fax this form to the number and person indicated at the top of the form
*Referring provider to follow up with individual
Disposition of urgent appointment:
Attended
Rescheduled
Did Not Show*
Declined*
Unable to Accept Insurance Type*
Assigned Case Manager/MD/Therapist Name: __________________________________________ Phone: (_____) _____________________
Date disposition sent to referral source: _______/_______/_______
Provider Communication Form (MH 707) form attached
Rev. 8/24/15
Confidential Patient Information, See CA W&I Code Section 5328
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