Urgent Behavioral Health Screening Form To Obtain Specialty Mental Health Assessment Template
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3URGENT Behavioral Health Screening Form to Obtain Specialty Mental Health Assessment
Please complete and follow algorithm
Referral Date: _____________________
***If this is an emergency, please call 911
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 notes H&P Assessment 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,
Substance and/or EtOH addiction and failed SBI
(e.g., work, home, self-care)
List B (check all that apply):
>2 psychiatric hospitalizations in the past 12 months
>2 incarcerations in past 12 months
Suicidal/homicidal preoccupation or behaviors in past 12 months
Diagnostic uncertainty
Referral algorithm based on checked boxes:
1-2 in list A and none in list B: Call health plan’s behavioral health network for consult
3 or more in list A and none in list B OR one in both lists: Refer to health plan’s behavioral health network
2 or more in list A and one in list B OR 2 or more in list B: Refer to County Department of Mental Health at (855) 425-8141
Substance and/or EtOH addiction and failed SBI alone: Refer to County 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: _______/_______/_______
Care Coordination between Providers (MH 707) form attached
Rev. 12/09/14
Confidential Patient Information, See CA W&I Code Section 5328
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