Referral Form Referral Form Initial Authorization & Concurrent UR Form Phoenix Connections – IOP 401 Clairborne Road Olathe, Kansas 66062 Referrals By Phone: (913) 324-3658 Referrals By Fax: (913) 768-1437 Today’s Date: Client’s Name: DOB: PERSONAL INFORMATION Referral Source: Person Completing the Form: Phone Number: Parent/Guardian Name: Relationship to Client: Parent/Guardian Phone Number: Parent/Guardian Address: DSM V Diagnosis: Admission Medications: Medication Changes with IOP: INSURANCE INFORMATION Kansas Medicaid — Amerigroup Kansas Medicaid — Cenpatico Kansas Medicaid — UBH Private Pay Medicaid Number: Is the child currently working with, or have they worked with the local mental health center: If so, who (please provide name and phone number)? Is the child on the SED waiver? If no, do you plan on applying for the SED waiver? AUTHORIZATION TYPE Initial Authorization Concurrent Authorization REFERRAL INFORMATION Note that for all of the following questions, the likelihood of an authorization is improved when specific examples of the behaviors are provided. RISK 1. Does the client currently have suicidal thoughts, feelings, or impulses? If yes, does the client have a plan, intent, and/or means? 2. Does the client currently have homicidal thoughts, feeling, or impulses? If yes, does the client have a plan, intent, and/or means? 3. Does the client have a history of suicidal or homicidal ideation? 4. Is the client physically aggressive? 5. Does the client exhibit any sexual acting-out behaviors? 6. Has the youth been in PRTF? If yes, how many times and the dates? 7. Does the client have any current substance/alcohol use? If yes, explain (i.e. drug, duration, date of last use, frequency, amount used, etc.). 8. Does the client have a history of substance/alcohol use? If yes, explain. 9. Does client have ability to care for self? 10. Has the client been a victim of abuse or neglect? If yes, explain (i.e. what occurred and if the client is still in contact with the abuser). 11. Symptoms (mark all that apply). Anxiety: SevereModerateMild Decreased Energy: SevereModerateMild Delusions: SevereModerateMild Depressed Mood: SevereModerateMild Hallucinations: SevereModerateMild Hyperactivity: SevereModerateMild Hopelessness: SevereModerateMild Inattention: SevereModerateMild Irritability/Mood instability: SevereModerateMild Impulsivity: SevereModerateMild Panic Attacks: SevereModerateMild Obsessions/Compulsions: SevereModerateMild Significant Weight Change: SevereModerateMild Sleep Disturbance: SevereModerateMild FUNCTIONING 1. Does the client have trouble building relationships? if yes, specify what kind of relationship (i.e.familial and/or peers). 2. Does the client have trouble keeping relationships? if yes, explain. 3. What are the client’s general appearance, hygiene, and self-care? 4. What are the client’s current sleeping/eating habits? 5. How is the client’s academic and behavioral functioning in school (i.e. suspension, IEP, truancy, etc.)? CO-MORBIDITY 1. Does the client have development disabilities? If so, explain. 2. Does the client have other medical conditions? RECOVERY ENVIRONMENT 1. Describe the types of stressors the client will encounter upon discharge, especially in the home environment. 2. Describe the types of supports the client will have upon discharge. RESILIENCY & TREATMENT HISTORY 1. Does the client have a history of mental health/psychiatric treatment? 2. Does the client have the ability to deal with stressors? 3. Was the client’s previous lower level treatment successful? Why or why not? 4. Is the client able to follow through with treatment recommendations? 5. Does the client have the ability to transition? ACCEPTANCE & ENGAGEMENT IN TREATMENT 1. Is the client able to understand/accept treatment? If so, how? 2. Is the client engaged in treatment? 3. Is the guardian able to understand/accept the client’s treatment? 3. Is the guardian engaged in the client’s treatment? FOR UTILIZATION REVIEW PURPOSES ONLY If requesting an additional week in IOP please explain the following: why are you asking for additional time, describe in detail what is happening that would require the youth to participate in services another week; how will you address these concerns, what do you expect to accomplish within this time frame, i.e. what is the plan during that week of treatment.