PSYCHOSOCIAL REHABILITATION SERVICES REFERRAL FORM
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Psychosocial Rehabilitation CMHRS Manual (H2017)
Service Definition: Psychosocial Rehabilitation is a program of two or more consecutive hours per day provided to groups of adults in a nonresidential setting. Individuals must demonstrate a clinical need for service arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. This service provides education to teach the individual about mental illness, substance abuse, and appropriate medication to avoid complication and relapse and opportunities to learn and use independent skills and to enhance social and interpersonal skills within a consistent program structure and environment.
Medical Necessity Criteria: The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from a mental, behavioral, or emotional illness that results in significant functional impairments in major life activities.
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Please select one:
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Spring Center—Seriously Mentally Ill Adults who are experiencing cognitive/medical/physical difficulties which impact activities of daily living.
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Atlantic House—Seriously Mentally Ill Adults residing in the Emporia area
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SECTION I
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Date of Referral:
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Consumer Name:
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Consumer ID #:
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Address:
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Phone Number:
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Primary Service Provider:
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Primary Program:
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Dietary Restrictions:
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Physical/Medical Restrictions:
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Potential Fall Risk?
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No
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Yes
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If yes, please explain:
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Diagnosis
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Axis I:
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Axis II:
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Axis III:
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Axis IV:
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Reason for referral (Why does this consumer need this particular service?)
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Specific services requested (What activities are expected to be provided as part of the service?)
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Program Eligibility Requirements
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Individual demonstrates a clinical necessity for this service arising from a condition due to mental, behavioral, or emotional illness which results in significant functional impairments in major life activities as evidenced by:
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AND
Individual must meet at least two of the following criteria on a continuing or intermittent basis:
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Has difficulty in establishing or maintaining normal interpersonal relationships to such a degree that he/she is at risk of psychiatric hospitalization or homelessness, or isolation from social supports, as evidenced by:
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Requires help 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 as evidenced by
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Exhibits such inappropriate behavior that repeated interventions documented by the mental health, social services, or judicial systems are or have been necessary as evidenced by:
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Exhibits difficulty in cognitive ability such that he/she is unable to recognize personal danger or recognize significantly inappropriate social behavior. “Cognitive” here is referring to the individual’s ability to process information, problem solve and consider alternatives, it does not refer to an individual with an intellectual or other developmental disability. As evidenced by:
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AND
Individual meets one of the following criteria
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Has experienced long-term or repeated psychiatric hospitalizations as evidenced by (provide date(s) and place(s) of hospitalization(s)):
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or
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Lacks daily living skills and interpersonal skills as evidenced by:
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or
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Has limited or non-existent support system as evidenced by:
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or
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Is unable to function in the community without intensive intervention as evidenced by:
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or
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Needs long-term services to be maintained in the community as evidenced by:
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DOCUMENTATION REQUIREMENTS (DOCUMENTATION THAT MUST BE ATTACHED TO THE REFERRAL FORM TO RENDER THE REFERRAL PACKET COMPLETE):
Following is a list of required D19 CSB forms needed when referring consumers to the Mental Health Day Programs. Please submit the following forms with the Psychosocial Rehabilitation Services Referral Form (all forms can be copied from the record provided they are current of a year or less.): A complete packet must be completed if a consumer has NEVER been admitted to a particular program or if they have been out of a program for over a year. Return referrals require only the Psychosocial Rehabilitation Services Referral Form AND any updated information. Whenever consumer information is updated please forward a copy to the Day Program the consumer attends.
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Forms from Primary Service Provider
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Date of Documentation
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Face Sheet
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Admission Assessment Form and/or Reassessment Form
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Copy of Insurance/Medicaid Card
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Copy of TB/PPD/Chest X-Ray
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Copy of last physical examination
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Most recent doctor's order and/or last hospital discharge order with current medications listed. Any relevant medical information (dietary restrictions, physical limitations, etc.)
(Please include all that are available.)
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Signature of Referring Staff:
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(Print Name and Title)
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SECTION II
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Disposition:
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Date Referral Received:
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Date Referral Accepted (or N/A, if referral not accepted):
*Note: Complete "Program Enrollment Form" and enter program into Pro-Filer.
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Specific Reason(s) Accepted to Program:
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OR
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Date Referral Not Accepted:
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Specific Reason(s) Not Accepted to Program:
*Note: Complete "Memorandum of Notification of Action for Medicaid Recipients" form, if applicable.
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Signature of Authorized Program Staff:
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(Print Name and Title)
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Additional Information for Program Assessment
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Additional Information Provided by:
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Printed Name
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Date
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Signature
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Psychosocial Rehabilitation Services Referral Form
Revised 1/2017
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