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)





Residential Supports:


Type of Support:

(circle one)







                        In-Home Waivered Service



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



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.