Referral for Crisis Stabilization Services (CSS) 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: —Please choose an option—SingleMarriedDivorcedWidow Dependent Children: —Please choose an option—YesNo # 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 Other Required Criteria person is NOT in need of immediate voluntary psychiatric hospitalization person is NOT a danger to self or others person is NOT voiced being intoxicated by drugs or alcohol, or under the influence in the last 24 hrs person has NOT been declared medically unstable person is NOT taking new or altered dosage of medication that result of which are yet unkown person has been asked about potentially dangerous items in their belongings person is free and/or fully treated against any visual human infestations B. Diagnostic Information Primary Diagnosis: Diagnosis Code: Secondary Diagnosis: Diagnosis Code: Other Diagnosis: Diagnosis Code: Diagnosed by: License/Credentials: Agency: Date of Diagnosis: Does the person have a history of drug abuse? YesNo If yes, describe: Does the person have a history of alcohol abuse? YesNo If yes, describe: Does the person have a Developmental Disability? YesNo If yes, describe: Does the person have other physical impairment(s)? YesNo If yes, describe: Presenting Problems(s) (please explain why the person is being referred for crisis 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: Phone: Therapist Name: Address: Phone: Person has a history of medication non-compliance?YesNo Does the person currently receive psychiatric medication monitoring?YesNo Person is being discharge with 14 days of necessary medication?YesNoN/A Person agrees that ALL medications including rescue inhalers are not permitted to be carried freely?YesNo Medications Dosage Frequency You may also attach a medication list here Please comment or indicate if this is a change in medication from the person's previous regimen: Somatic Care Physician Name: Address: Phone: Please indicate or comment on any relevant medical/somatic history including assessment of general physical health (illness, physical disabilities, allergies): Physical health assessed by ER physician/somatic physician? YesNo Date: If yes, ER physician/somatic physician name and credentials D. Rehabilitation Services Is the person currently involved in a structured day program? YesNo Name of program: Contact person: Recommended rehabilitation and/or treatment goals: Person's discharge plan following 10 day crisis stay: E. Authorization for Services ASO Care Manager (full name): Both Need Requested When Obtaining Authorization T2048 Residential room and board YesNo H0018 Residential Crisis Services YesNo Date Range to Authorization #: 1:4 staff to person ratio coverage is acceptable for person's needs? YesNo Clinical Rationale: Other insurance authorization information (if applicable): F. Signatures Face-to-face evaluation completed by a psychiatrist occurred as part of the referral: YesNo -- If yes, complete Section G -- If no, person gives consent to participate in a face-to-face evaluation within 24hrs of admission to crisis services: YesNo 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 Signature of Supervisor (if applicable) Date: Printed Name Credentials Email (by providing your email address you will receive a copy of this referral) G. This following section is to be completed by psychiatrist or appropriately privileged mental health professional: I have assessed the physical health of this person: YesNo The person needs a physical exam or somatic follow up: YesNo Face-to-face evaluation completed by psychiatrist: YesNo Mental Status Examination/Screening Assessment: Signature of Psychiatrist or Appropriately Privileged Mental Health Professional Date: Printed Name Credentials If physical health has not been assessed by a medical professional, a somatic appointment will need to be scheduled no more than 72 hours after admission to residential crisis stabilization services facility.