Capitation Project Referral Form ________________
Client Name
BALTIMORE CITY CAPITATION PROJECT REFERRAL FORM
SEND COMPLETED REFERRALS:
To: Alicia Torres
Fax: (410) 837-2672
Phone: (410) 837-2647
PLEASE NOTE: All questions must be completed in order
for the referral to be considered and all
supporting documentation must be attached.
Date:
Client Name:
Referral Source: Name: _______________________________
Facility/Agency: __________________________
Phone Number: ___________________________
FAX Number: _________________________
Reason for referral: (If state hospital, please state what has kept the client in the hospital)
DOB: SS#: Gender: Male Female
Last Known Address & Phone in Community:
Planned address & phone at time of discharge:
Other contact name, address & phone:
Income Source: SSI SSDI Pending None Other ___________
Insurance Coverage: Medical Assistance Medicare Private
VA Benefits None Other_____
Diagnosis:
AXIS I: ___________________ AXIS II: ____________________
___________________ ____________________
AXIS III: (Please list all medical conditions)
_________________________________________________________
_________________________________________________________
_________________________________________________________
Medications: (Somatic and Psychiatric)
Active Medical Problems Requiring Ongoing Medical Attention:
Current Community Somatic Care Provider:
Name: ________________________
Location: ______________________
Date of Last Visit: _______________
Substance Abuse: (Check)
Heroin: None Past Present Frequency of use_____ How used______
Cocaine: None Past Present Frequency of use _____ How used______
Alcohol: None Past Present Frequency of use_____ How used______
Marijuana: None Past Present Frequency of use_____ How used______
Other: ________None Past Present Frequency of use______ How used_____
Legal Issues (check) Charges Pending On Probation/Parole None Conditional Release/NCR Past Incarceration
Explain all legal issues checked above:
Capitation Project Referral Form ________________
Client Name
Medical Hospitalizations and Dates within the last two years:
Psychiatric Hospitalizations (state, private, and general hospitals) and Dates within last two years (see eligibility criteria):
Facility Dates
_________________________________ __________
_________________________________ __________
_________________________________ __________
_________________________________ __________
ER Visits for Mental Health Services and Dates within last two years (see eligibility criteria):
Facility Dates
_________________________________ __________
_________________________________ __________
_________________________________ __________
_________________________________ __________
_________________________________ __________
_________________________________ __________
_________________________________ __________
Past Outpatient Psychiatric Treatment:
Mental Status: (Check all that apply)
Orientation: Person Place Time
Mood (what client reports over the last 2 weeks): Happy Sad Neutral
Affect: Euphoric/Manic Mid Range Dysphoric
Thought Process: Organized/Linear Disorganized Illogical Loose Assoc./Flight of Ideas
Thought Content: Thoughts Focused On __________________________
Psychotic Symptoms: Hallucinations: YES NO If yes, type:______________________
Delusions:_(describe)_________________________________________________
Suicidal Thoughts: Yes No Plan: Yes NO History of: Yes No
Homicidal Thoughts: Yes No Plan: Yes NO History of: Yes No
Insight: Poor Fair Good
Judgment: Poor Fair Good
Short Term Memory: Intact Impaired
Long Term Memory : Intact Impaired
Since the individual may refuse participation in the program, or may not be accepted for the program, an alternative community service plan needs to be developed.
Please describe the plan for community services other than Capitation.
________________
Client Name
To be completed by the treating physician:
Based on my observations and treatment of _______________________, it is my assessment that the individual has the capacity to understand the nature of the program and has the capacity to voluntarily provide informed consent to participate in the program, or has a guardian of person who can provide informed consent. The individual being referred is aware that he/she will be assigned to either Chesapeake Connections at the North Baltimore Center or Creative Alternatives at Bayview Medical Center.
________________________________
Name of Physician-Please Print
________________________________ ________________
Signature of Physician Date
Release of Information Authorization:
I, _________________________ (client name), give permission for Baltimore Mental Health Systems, Inc. To release medical records about my care to one or both of the following programs for the purpose of referring me for mental health care:
Creative Alternatives at Johns Hopkins Bayview Health System
Chesapeake Connections at The North Baltimore Center
Signed, _________________________________ (signature of client)
Date: _________________________