Adult Mental Health Case Management Referral Ramsey County printable pdf download

Adult Mental Health Case Management Referral Ramsey County

Adult Mental Health Case Management Referral

Statement of Need

COMPLETION OF THIS FORM AND A CURRENT (6 months or less) DIAGNOSTIC ASSESSMENT ARE

NECESSARY TO DETERMINE/ MAINTAIN SERVICE ELIGIBILITY.

THE ATTACHED DIAGNOSTIC ASSESSMENT MUST MEET THE DHS REQUIREMENTS IN

9505.0372

MINNESOTA RULE

SUPPART 1

Client Name:

DOB:___/___/___

Race: ______________

Client Phone: __________________

Social Security Number: _________________

Client’s Permanent Address: (non Ramsey County residents should be referred to their County of Residence)

Street

Apt # _____________

City:

County: _______________

Zip:_______________

Language if other than English: ________________________ Does client need interpreter: _____________

Is the client currently at the above address or are they in a facility?

at address

in facility

If in a facility: Name: _____________________

Station: ______________

Phone: _________

Admit Date: __________ Anticipated Discharge Date: _________ Treating MD: _________________

Current Diagnosis - DSM 5

ICD 10 Codes

______________________________________________________________

_____________

2._____________________________________________________ ICD 10 Codes__________

3._____________________________________________________ ICD 10 Codes__________

Rule outs and unspecified diagnoses will not be accepted for Adult Mental Health Case management

IN MY OPINION AS A LICENSED MENTAL HEALTH PROFESSIONAL THE ABOVE NAMED

ADULT:

IS NOT seriously and persistently mentally ill as defined in MN Statute

2. ____ IS seriously and persistently mentally ill and meets the criteria for case management services as

indicated below (Please check A, B, C, D or E to identify how this adult meets the criteria).

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Adult Mental Health Case Management Referral Ramsey County