referral test – Intrust Healthcare

Date*

Client’s Name:

Guardian’s Name:

Custody of: *

Custody of:*

Parent
DCBS
DJJ

Has the guardian/client been contacted about this referral? *

Has the guardian/client been contacted about this referral?*

Yes
No

Address:

Phone:

School/ Workplace:

Grade:

DOB or Age:

Referring Individual and Agency:

Agency Phone:

Checklist for Eligibility

Criteria

Does the client have a medical card?

Does the client have a medical card?

Yes
No
Not Sure

MCO:

MAID #:

Does client have a primary insurance:

Does client have a primary insurance:

Yes
No
Not Sure

Insurance Number:

Does the client have a diagnosed emotional or behavioral disorder?

Does the client have a diagnosed emotional or behavioral disorder?

Yes
No
Not Sure

If so, what is diagnosis?

Has the client been diagnosed with a Severe Mental Illness?

Has the client been diagnosed with a Severe Mental Illness?

Yes
No
Not Sure

If so, what is diagnosis?

Are behaviors causing impairment to daily functioning?

Are behaviors causing impairment to daily functioning?

Yes
No
Not Sure

How long have behaviors occurred:

Has the client had any mental health placements?

Has the client had any mental health placements?

Yes
No
Not Sure

How many placements in the last two years?

Has the client ever been removed from the home?

Has the client ever been removed from the home?

Yes
No
Not Sure

If yes, where were they placed?

Reasons for Referral

School

School

Home

Home

Community

Community

Limitations:

Limitations:

Has the child been seen by a therapist or or school personnel before?

Has the child been seen by a therapist or or school personnel before?

Yes
No

Additional information:

Referral to Therapy

Referral to Therapy

Yes
No

Therapist Notified:

Date Notified:

Referral to Case Management

Referral to Case Management

Yes
No

CM Notified:

Date Notified: