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

community following Agency

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)

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