Respite Services Referral – Allegany County

Referral for Respite Services (RS)

Inpatient Admission Prevention Level of Care

ALL INFORMATION ON REFERRAL IS REQUIRED AND MUST BE COMPLETED

Name:

Date:

Address:

Telephone:

Date of Birth:

Social Security #:

Gender:

Race:

Education:
Below 12th gradeGEDHigh School DiplomaCollege

Employment:

Emergency Contact:

Telephone:

Current Living Arrangement:

Marital Status:

Dependent Children:

# in Family:

SSI:

SSDI:

Food Stamps:

Other Income:

Veteran:
YesNo

VA Income:

VA Medical Benefits:

Medical Assistance #:

Medicare #:

QMB:
YesNo

Other Medical Insurance:

Policy #:

Other Payment Source(s):

A. Eligibility Screening (all must apply)

requires inpatient admission prevention level of care not admission alternative

for clinical reasons, requires a temporary separation from current living situation

person understands and has stated willingness to comply with CSS rules

person expects, with staff support, to be able to comply with treatment recommendations

person is able, with staff support, to care for physical needs and personal hygiene

B. Diagnostic Information

Primary Diagnosis:

Diagnosis Code:

Secondary Diagnosis:

Diagnosis Code:

Other Diagnosis:

Diagnosis Code:

Diagnosed by:

License/Credentials:

Agency:

Date of Diagnosis:

Presenting Problems(s) (please explain why the person is being referred for respite services):

C. Health Services

Has the person previously been admitted to a psychiatric hospital? YesNo

Place of last hospitalization:

Other relevant history:

Psychiatrist

Name:

Address:

Telephone:

Therapist

Name:

Address:

Telephone:

Person has a history of medication non-compliance?YesNo
Does the person currently receive psychiatric medication monitoring?YesNo

Medications

Dosage

Frequency

You may also attach a medication list here

Medical Conditions/Limitations/Allergies:

Date of last physical:

Physician:

Address:

Telephone:

Risk Assessment
SuicidalityIdeationPlanPrior Attempts (if known)

Other Risk Behavior:

Substance Abuse:

D. Rehabilitation Services

Recommended Service Needs:
Respite Care is Needed:
Specific future timeImmediatelyIntermittently

Expected Duration of Respite Care:

From

Frequency, level and type of staff contacts needed:

E. Authorization for Services (to be completed by Archway Station, Inc. Respite Staff)

ASO Care Manager (full name):
Both Need Requested When Obtaining Authorization
HOO45 Respite Services, full day: YesNo

Date Range

Authorization #:

Referral Source (name of agency; mental health professional or individual):

F. Signatures

Referral source understands that a person discharged for violation of rules or behaviors presenting a risk to self, staff, or others may require emergency care. Secondary level of care or discharges lasting longer than 24hrs will require the submission of a new referral and assessment.
Referral Source: Must be referred by a Licensed Mental Health Professional. A “Licensed Mental Health Professional” eligible to make referrals to a PRP is defined as a Psychiatrist, CRNP-PMH, Licensed Psychologist, LCSW-C, LCPC, APRN-PMH, LCMFT, LCADC, LCPAT, LGMFT, LGADC or LGPAT. LGPC, LGMFT, LGADC, LGPAT and LMSW staff may only make referrals if they are currently in a formal clinical supervision arrangement with a supervisor approved by the Maryland Board of Professional Counselors and Therapists or the Maryland Board of Social Work Examiners, as applicable. (Supervisor's name, title and location must be provided). Referrals from non-mental health professionals who do not have a mental health specialty are not permitted. RN-C, CAC- AD and CSC-AD are not eligible to make referrals. The Licensed Mental Health Professional must be actively enrolled as a Medicaid provider.

Individual Signature

Date:

Signature of Referring Mental Health Professional / Physician

Date:

Printed Name

Credentials

Email (by providing your email address you will receive a copy of this referral)

Signature of Supervisor (if applicable)

Date:

Printed Name

Credentials