Metro Crisis Coordination Program - Intake/Referral Form

 

Please print out these sheets, fill them out and fax them to: MCCP at 612-869-6743 along with the Client’s ISP and Individual Abuse and Prevention Plan if applicable.

 

General Information:                                     Todays’ Date: ______________

 

Type of Referral:                 Preventative           

(circle one)                           Emergency

 

Check here if you are looking for Technical Assistance (assigned to a behavior analyst to do an assessment)______

Check here if you are looking for a crisis bed________

Check here if you are looking for both______

 

Is this person currently in the hospital?          YES___   NO____,  If yes, which hospital, phone # and contact     

 

Current Funding:             (circle one)       

MA Regular Waiver                MA Crisis Waiver 

Consumer Support Grant        Family Support Grant

CDCS         CADI           TEFRA        ICF/MR

None                             Other_______________________________

 

Client Information:

 

Client Name: ______________________________

 

DOB:    (mm/dd/yy)_________________________

 

SSN #: _______________________

 

Address: ____________________________

 

___________________________________

 

Phone: __________________________

 

County of Residence: _____________________

                                               

 

Reason for Referral & Miscellaneous Information: (Please be breif, you can explain in full when you are contacted by the behavioral analyst.)

____________________________________________________________________________________

 

____________________________________________________________________________________

 

 

 

Referral Contact Information:

 

Referred By (Your name): ______________________

 

Relationship:  (CM, Guardian, residental provider, etc)_____________________

 

Phone: __________________________

 

Other Contact Information: 

Conservator Information:

 

Conservator Name: ____________________________

 

 

 

What are the highest risks  at this time?________________________________________

Rate the following risks (low, medium, high):

Loss of placement at this time:   L     M     H

Harm toward others:   L    M    H

Harm toward self:   L    M    H

Harm by others:    L   M    H

 

Relationship: _________________________________

 

Conservator Phone: ___________________________

 

Conservator Address: __________________________

                               

                                _____________________________

                               

                                Legal Status:    

(circle one)

                                Self

                                Private

                                State

 

Residential Supports:

 

Type of Support:

(circle one)

                        SLS

                        SILS

                        ICF

                        Foster

                        Respite

                        PCA

                        In-Home Waivered Service

                        None

 

Provider Name: ______________________________

 

Contact Person: ______________________________

 

Phone: _____________________________________

 

Alt. Phone: __________________________________

 

 

County Case Management Information:

 

County of $ Responsibility: ______________________

 

Case Manager: ________________________________Mailing addres: ____________________________

 

Phone: _________________ Fax: ­­­­­­­­­­­­­­­­­­­­­­­_____________________Email:____________________________

 

 

 

Diagnosis  & Medical Information:

 

MA-PMI #: ______________________

 

 

MR Level:

(circle one)           Boderline,  Mild,   Moderate,  Severe,  Profound,  Related Condition

 

 

 

Primary Psychiatric Diagnosis: ____________________________

 

Primary Medical Diagnosis: _______________________________

 

Other diagnosis (if applicable): ____________________________

 

(circle one of the following in each question)

 

Seizure Disorder: YES          NO

 

Allergies:              YES          NO

 

Daily Living Skills:               Independent           Needs Assistance    Needs Prompts

 

Communication:                  Verbal                     Non Verbal              Limited

 

 

(please check yes or no for the following)

 

 

Previous Psychiatric Hospitalization?       YES          NO

Previous  RTC Placement?                      YES          NO

Is there a Behavior Support Plan?          YES          NO

Crisis Prevention Plan?                            YES          NO

Positive Support Transition Plan?            YES          NO

Individual Abuse Prevention Plan?          YES          NO

On any Psychtropic Meds?                      YES          NO

 

If so, please list meds (just names, please)

 

_____________________________________________________

 

 

 

Education/Work Information:

 

Please cirlce which program client is involved in:

 

                Day Program

                Work Program

                School

 

Name of School, Day program, Employer: __________________

 

Contact person: _________________________

 

Phone: ________________________________

 

Type of Work/Activity: _____________________

 

 

After this is completed please fax along with the client’s Individual Abuse Prevention Plan and ISP to 612-869-6743, attention: INTAKE

 

MCCP will process the intake and assign it to a Behavior Analyst who will make initial contact with team members.