ARCHWAY STATION, INC.

ADULT REFERRAL for Supported Employment (SE)
Individual Placement and Support (IPS) Services

Applicant Information

Name Street

Medicaid & Current Entitlements

Do you have a relative that is currently employed by Archway Station, Inc.? —Please choose an option—YesNo

Referral Source

Outpatient Mental Health Provider

Same as Referral SourceOther

Diagnosis

Please select Primary Diagnosis and specify ICD-10 Code

Diagnosis may include other specifiers WITH THE EXCEPTION OF “single episode”, “in partial remission”, or “in full remission”; and may co-occur with an intellectual disability or neurodevelopmental disorder (i.e., communication disorder, autism spectrum disorder, attention deficit/hyperactivity disorder, motor disorder, or other neurodevelopmental disorder), provided that the co-occurring diagnosis does not meet eligibility criteria for Developmental Disability Administration services and the most prominent symptoms, behavior, or functional impairments are primarily attributable to a diagnosed serious mental illness and NOT primarily attributable to an intellectual disability or neurodevelopmental disorder.

—Please choose an option—SchizophreniaSchizophreniform DisorderSchizoaffective Disorder, Bipolar TypeSchizoaffective Disorder, Depressive TypeOther Specified Schizophrenia Spectrum and Other Psychotic DisorderUnspecified Schizophrenia Spectrum and Other Psychotic DisorderDelusional DisordersMajor Depressive DisorderUnspecified Depressive DisorderBipolar I Disorder, Current or Most Recent Episode ManicBipolar I Disorder, Current or Most Recent Episode DepressedBipolar I Disorder, Current or Most Recent Episode HypomanicBipolar I Disorder, Current or Most Recent Episode UnspecifiedOther Specified Bipolar and Related DisorderBipolar II DisorderSchizotypal Personality DisorderBorderline Personality Disorder

Primary ICD-10 Code

Functional Impairments / Eligibility Information

The individual being referred must demonstrate impaired role functioning, on a continuing or intermittent basis, for at least 2 years, compromising three serious functional impairments including:

Marked inability to maintain independent employment, characterized by an established pattern of unemployment, underemployment, or sporadic employment, which requires intervention by the behavioral health system beyond what is typically available in mainstream workforce development or social service organizations, and which is primarily attributable to symptoms, behavior or other functional limitations primarily associated with a diagnosed serious mental illness and NOT primarily associated with an intellectual disability or neurodevelopmental disorder. ; and
Two or more of the following functional limitations (please check all that apply): Social behavior that results in interventions by the behavioral health system.Inability, due to cognitive disorganization, to procure financial assistance to support living in the communitySevere inability to establish or maintain a personal support systemNeed for assistance with basic living skills.
Please list other diagnoses (include ICD-10 codes), if applicable.

Employment Questions

Is the individual currently employed? YesNo Is the individual interested in competitive employment and have a desire to work in the community? —Please choose an option—YesNo Does the person have a current DORS Counselor? —Please choose an option—YesNo Describe any problems or difficulties with work

Supporting/Clinical Documentation

Supporting or clinical documentation may be included to further demonstrate and support the individual’s need for Supported Employment services. Documentation may include relevant mental health diagnoses, clinical findings, functional limitations, barriers to employment, or other information that demonstrates how the individual’s mental health needs may impact their ability to obtain or maintain employment and supports the need for employment-related assistance.

Signatures

I understand that this application is being sent in order to determine if I am eligible to obtain services from Archway Station, Inc. This application does not bind me to receive services. I still have the right to change my mind later. I give Archway Station, Inc. permission to communicate with the referral source to discuss and share medical and mental health history and information necessary for my referral.

Completed referrals can be submitted via fax or mail.

Please send to the attention of “Intake Coordinator”.
Fax to (301) 777-8020 or Mail to Archway Station, Inc., 45 Queen St., Cumberland, MD 21502.