Mobile Med Referral Form

Client Name *

First

Last

Client Date of Birth *

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client Phone *

Client Social Security Number *

Referral Source *

Agency Name *

Agency Phone Number *

Carelon Health Option *

Yes

MA# *

County Funded *

Yes

County Notified *

Yes
No

Case Management *

Yes
No

Case Management Provider *

Name of Case Management Contact Person *

Agency Phone Number *

Current Psychiatrist *

Current Psychiatrist Agency *

Agency Phone Number *

MUST MEET CRITERIA I, II, and III

I. *

The person must be 18 years of age or older and have a primary diagnosis of a serious mental illness (Major Depressive Disorder, Bipolar Disorder, Schizophrenia Spectrum, and Other Psychotic Disorders, etc.) and be prescribed psychotropic medications.

II. The person needs community-delivered psychiatric nursing services to prevent the need for more restrictive levels of care to improve community tenure. The person must meet one of the following *

Receiving case management or other ambulatory services and in need of intensive medication management to prevent the need for a higher level of care (i.e. inpatient treatment).
Current inpatient admission or readmission due to non-adherence or inconsistent adherence to the prescribed medication regime.
Initiation or revision of a complex medication regime.
Medical diagnosis that requires coordination of physical and behavioral health issues, including medication management.

III. *

An up-to-date psychiatric evaluation and the current list of medications must be provided.

Rational for Mobile Medication Request *

Recommended Frequency *

Service History-Previous and Current Services, Admissions, ETC.

Previous Services/Admissions (if known)

Suicidal Current County

Provider of Service/Contract Name & Phone (if known)

CURRENT CLINICAL STATUS

Suicidal or homicidal ideations *

Yes
No
Active
Passive

History of suicidal or homicidal attempts *

Insight/Judgement *

Mood and affect *

Safety Concerns *

Please describe the unlisted safety concern and any additional comments.

PSYCHOSOCIAL INFORMATION

Education Level *

Legal History *

Social Support / Housing *

Trauma History *

Emotional
Physical
Sexual