MENTAL HEALTH SUPPORTIVE CASE MANAGEMENT OF HERKIMER COUNTY

REFERRAL FOR CHILD AND YOUTH CASE MANAGEMENT SERVICES

PROGRAM REQUESTED:

£ Supportive £ Intensive £ Home and Community Based

Case Management Case Management Services Waiver

Referrals for any residential program licensed by the New York State Office of Mental Health, including Family Based Treatment, Teaching Family Homes, Community Residences, and/or Residential Treatment Facilities, must also be reviewed by the Single Point of Entry. For information on how to make a referral to one of these programs, please call 792-7143.

CLIENT INFORMATION:

Name: _______________________________________ Date of Referral: _________________________________

Address: _____________________________________ City, State, Zip: __________________________________

Phone: _____________________ Sex: _____________ DOB: ______________ School: ____________________

Social Security #: _____________________ Medicaid #: ___________________ Other Insurance: _____________

Mother (include name, address, phone): _________________________________________________________________

Father (include name, address, phone): _________________________________________________________________

Siblings (include ages): ___________________________________________________________________________

Current guardian/custodial adult: __________________________________________________________________

Lives with: £ Parent(s) £ Guardian £ Other: ______________________________________

Emergency contact: _____________________________ Relationship: _______________ Phone: ______________

Please check all that apply:

£ Functional limitations in the areas indicated: £ Self-care £ Family life

£ Social relationships £ Learning ability £ Self-direction

£ Met criteria for a rating of 50 or less on the Children’s Global Assessment Scale in the past year

£ Meets criteria for a rating of 50 or less on the Children’s Global Assessment Scale currently

£ Experienced one of the following in the last 30 days:

£ Serious suicidal symptoms or other life-threatening destructive behaviors;

£ Significant psychotic symptoms; and/or

£ Behavioral problems causing a risk of personal injury or significant property damage.

Referral Source: ____________________________ Name: ____________________ Relationship: ____________

Address: _________________________________________ Phone: ______________ Fax: __________________

Reason for referral at this time (please state specifically how these services will benefit the child or youth): ______

____________________________________________________________________________________________

PSYCHIATRIC INFORMATION:

Clinical Treatment Provider: ______________________________________________ Phone: ________________

Therapist: _______________________________________ Psychiatrist: _________________________________

Diagnosis: Axis I: _________________________________________________________________________

Axis II: ________________________________________________________________________

Axis III: _______________________________________________________________________

Axis IV: _______________________________________________________________________

Axis V: _______________________________________________________________________

Medications (please list dosage and attach additional sheets if necessary): _________________________________

____________________________________________________________________________________________

Does the child or youth take medications as prescribed? Yes £ No £

SUICIDE/HOMICIDE RISK: Yes £ No £ Unknown £

Please describe recent suicidal ideation, suicide attempts or homicidal ideation: _______________________

_______________________________________________________________________________________

Please describe past history of suicidal ideation, suicide attempts or homicidal ideation: _________________

_______________________________________________________________________________________

PSYCHIATRIC HOSPITALIZATION: Unmet Needs £ Needs Met £ Unknown £

Currently inpatient? Yes £ No £ Admit date: _________________ Anticipated D/C date: _____________

Please list any previous psychiatric hospitalizations: __________________________________________________

____________________________________________________________________________________________

MENTAL HEALTH TREATMENT: Unmet Needs £ Needs Met £ Unknown £

Please list any previous outpatient treatment, including current: _________________________________________

____________________________________________________________________________________________

Brief history of illness: _________________________________________________________________________

____________________________________________________________________________________________

Does the child or youth have a history of violence to self or others? Yes £ No £ If yes, please explain.

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Behavioral Symptoms (check all that apply): £ Depression £ Anxiety

£ Phobias £ Suicidal ideation or attempt £ Property destruction £ Aggression £ Cruelty to animals £ Fire-setting £ Sleep problems £ Bed-wetting or soiling £ Physical complaints £ Developmental delays £ Inappropriate sexual behavior £ Other: _____________

HEALTH CARE: Unmet Needs £ Needs Met £ Unknown £

Primary Care Provider: __________________________________________________ Phone: ______________

Medical Conditions: ____________________________________________________________________________

Allergies: ____________________________________________________________________________________

SUBSTANCE ABUSE: Unmet Needs £ Needs Met £ Unknown £

Please list past and present use and treatment: _______________________________________________________

____________________________________________________________________________________________

Treatment Provider: _______________________ Clinician: _________________ Phone: ____________________

LEGAL INVOLVEMENT: Unmet Needs £ Needs Met £ Unknown £

History of violence, PINS involvement, Juvenile Delinquent status, Court involvement, and probation: ___________

____________________________________________________________________________________________

Contact (probation officer, PINS worker, etc.): _______________________________ Phone: ______________________

FINANCIAL MANAGEMENT: Unmet Needs £ Needs Met £ Unknown £

Check if applicable: SSI £ Application pending for: Medicaid £ SSI £

Medicaid #:_________________ Medicare #:______________________ Other Insurance:____________________

Please list any financial management needs, including SSI application and/or family income source: ____________

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LIVING ARRANGEMENT: Unmet Needs £ Needs Met £ Unknown £

History of out-of-home placement: £ Foster Care £ Group Home £ RTF £ Other: ____________________

Please list current living arrangement: ______________________________________________________________

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EDUCATIONAL FUNCTIONING: Unmet Needs £ Needs Met £ Unknown £

£ Academic functioning below grade level £ Special education services (Classification: _________)

£ School suspensions and/or expulsions £ Aggressive towards teachers

£ Conflict with peers £ Unresponsive to teacher direction

£ Fails to participate £ Lacks friends

£ Inconsistent attendance £ Currently on home instruction

Summary of school performance and history: ________________________________________________________ ____________________________________________________________________________________________

____________________________________________________________________________________________

TRANSPORTATION: Unmet Needs £ Needs Met £ Unknown £

Please list current transportation needs: _____________________________________________________________

SOCIAL SUPPORTS/FAMILY FUNCTIONING: Unmet Needs £ Needs Met £ Unknown £

Supports/social clubs: __________________________________________________________________________

Leisure time activities: __________________________________________________________________________

Identified needs: _______________________________________________________________________________

£ Supportive family unable to cope with child’s disability £ Parent(s) unable to control child’s behavior

£ Family violence £ Substance abuse by parent(s)

£ Parent(s) have criminal record £ Parent(s) are intellectually limited

£ Parent(s) inconsistent with treatment and/or medication £ Current CPS involvement

£ Psychiatrically ill parent(s) History of hospitalizations: £ Yes £ No

£ Psychiatrically ill sibling(s) History of hospitalizations: £ Yes £ No

Is child/youth aware of this referral? Yes £ No £ Is child/youth interested in services? Yes £ No £

Please list child or youth and family strengths and skills: _______________________________________________

____________________________________________________________________________________________

SERVICE NEEDS: Needs Met Low Priority High Priority

Psychiatric Services: £ £ £

Medication Management: £ £ £

Substance Abuse Services: £ £ £

Living Arrangements: £ £ £

Self-Care: £ £ £

Legal: £ £ £

Benefits/Financial: £ £ £

Transportation: £ £ £

Work/School: £ £ £

Social/Family Relationships: £ £ £

Crisis/Safety Planning: £ £ £
Please add any additional comments: ______________________________________________________________

____________________________________________________________________________________________

Required information: Please send form and required information to:

£ Consent for release of information SPOE Coordinator, Office of Community Services

£ Psychiatric evaluation (most recent) 230 Maple Street

£ Treatment plan (most recent) Glens Falls, NY 12801

£ Admission/discharge summaries (most recent) Phone: (518) 792-7143 Fax: (518) 792-7166