Service Referral Form Mental Health Skill Building | Pyschosocial Rehabilitation | Crisis Stabilization Service Area * Note: Psychosocial Rehabilitation is offered only in Roanoke & Rocky Mount at this time Roanoke Lynchburg Rocky Mount Danville Client Name * First Name Last Name Date of Birth * MM DD YYYY Address Phone * (###) ### #### Gender * Male Female Prefer Not to Say Race * Marital Status Medicaid # Social Security # Additional Insurance Diagnostics Code(s) & Descriptions(s) MENTAL HEALTH SKILL BUILDING CRITERIA must meet all of the following Is the primary diagnosis schizophrenia/other psychotic disorder, Major Depressive Disorder-Recurrent, or Bipolar I or II? If NO, a physician MUST have documented any other mental health disorder within the last year to include all of the following: Serious Mental Illness (SMI), Severe and recurrent disability, Functional limitations in the member’s major life activities which are documented in the member’s record; and Member requires individualized training in order to achieve or maintain independent living in the community. YES NO Does the individual require training in acquiring basic living skills such as symptom management; adherence to psychiatric and medication treatment plans; development and appropriate use of social skills and personal support system; personal hygiene; food preparation; or money management? YES NO Does the individual have a prior history of any of the following? Psychiatric hospitalization, Crisis Stabilization (any), Intensive Community Treatment (ICT), (PACT) services, Placement in a psychiatric residential treatment facility (RTC Level C); or Temporary Detention Order (TDO) evaluation as a result of decompensation related to serious mental illness. YES NO Has the individual had a prescription for anti-psychotic, mood stabilizing, or anti-depressant medications within the last 12 months? YES NO PSYCHOSOCIAL REHABILITATION (VIP) CRITERIA must meet 2 of 4 Does the client experience difficulty in establishing and maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization, homelessness, or isolation from social supports? YES NO Does the client experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition or managing finances to such a degree that health or safety is jeopardized? YES NO Does the client exhibit such inappropriate behavior that repeated interventions documented by mental health, social services or the judicial system are or have been necessary. YES NO Does the client exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate behavior in daily life? YES NO CRISIS STABILIZATION CRITERIA must meet 2 of 4 Is the client having difficulty in establishing or maintaining interpersonal relationships due to the crisis situation to such a degree that they are at risk of hospitalization, homelessness, or isolation from social supports? YES NO Is the client exhibiting such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary? YES NO Is the client exhibiting difficulty in cognitive ability as a result of the crisis such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior? YES NO Does the client’s current crisis cause issues with completing basic living skills, such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized? YES NO Problem Areas Identified for this Client Referral Party Name First Name Last Name Referral Party Address Referral Party Phone (###) ### #### Referral Party Email Thank you! Your referral has been received!
