Baltimore Mental Health Systems, Inc.
APPLICATION FOR RESIDENTIAL REHABILITATION PROGRAMS
(Revised 11/10)
This application is to be used for individuals requesting residential placement in Baltimore City. These services are coordinated by the Adult Services Team at Baltimore Mental Health System, Inc. (BMHS). Placements are in licensed Residential Rehabilitation Programs (RRP). The purpose of this application is to provide essential information needed to evaluate eligibility for services, and the level of care needed by the applicant. Services are available to adults (18 years of age or older) with priority given to Baltimore City residents with a severe and persistent mental illness. Upon receipt of the completed and signed application, the applicant will be referred to a program with a vacancy or placed on a waiting list if no vacancy is available.
Two signatures by the applicant (client) must be enclosed with the application.
This application is for:
______
Client name
______
Referral Source: Name Agency Phone #
______
Agency Address
Please feel free to call Baltimore Mental Health Systems, Inc. at (410) 837-2647 with any questions or concerns. Please return the completed application and, if possible, a copy of the most recent psychosocial assessment or psychiatric evaluation. All sections of the application must be completed. Please put “N/A” when something is not applicable.
Baltimore Mental Health Systems, Inc.
201 E. Baltimore St., Ste 1340
Baltimore, MD 21202
Office# 410-837-2647
Fax# 410-837-2672
BALTIMORE MENTAL HEALTH SYSTEMS, INC.
APPLICATION FOR RESIDENTIAL REHABILITATION SERVICES
(I) Today’s Date:______
Applicant’s Name: (Last) (First) (M.I.)____
Last known address in community:
______
______
Telephone # .
Date of Birth: Social Security#:______
Gender:______Race:______
Marital Status:______
Current Entitlements and Income (Fill in amounts and/or insurance numbers)
SSI SSDI: Other Income:______
Medicaid (MA)# Medicare #:______
Other Insurance Name & Number:______
(II)Referral Source Name: Agency:______
Telephone # ______Fax #______
Psychiatrist Name Telephone #______
Other Providers (Mobile Treatment, PRP, Case Management, Outpatient)-(please circle)
Name of Program Contact Person Telephone#
Primary Contact (applicant, therapist, family, member, friend, other)-(please circle)
Name of Contact Telephone # Relationship to Applicant
______
(III) Current Psychiatric Diagnosis: DSM-IV Codes:
Axis I: ______
______
Axis II: ______
______
Axis III:
Axis IV:
Axis V: (GAF)
Number of psychiatric hospitalizations:______
List psychiatric hospitalizations (current or most recent first):
Date Location Admission Discharge .
.
.
.
.
.
Applicant’s Name______DOB ______
(IV) Name of Primary Care Provider (PCP):______
Address:______
Telephone #:______
Somatic Issues:______
______
(V) All Current Medications: (Psychiatric and Somatic) Current
Name Dosage-Frequency
______
______
______
______
______
Current ability to take medicine:
Independently With reminders With daily supervision ______
Refuses medication Meds not prescribed ______
Comments:
(VI) Legal History/Forensic Involvement
Has the applicant ever been arrested? Y N_____
On Probation or Parole? Y N_____
List any reported convictions
______
Parole or probation officer & Phone #:
Has applicant been found NCR? Y N_____
Is on (or will be on) conditional release? Y N_____
(VII) Substance Use/Abuse History
Drug Used (including alcohol) Period of Use Frequency How Used
______
______
______
______
______
Drug Last Used Date Amount How Used
______
Substance Abuse Treatment History (date and location)
A.A.______N.A. ______
Detox ______
Inpatient Services ______
Outpatient Services______
______
Applicant’s Name DOB______
(VII) Risk Assessment (Never, past week-month, past month-year, past 2+years)
Suicide Attempts:______
Suicidal Ideation:______
Aggressive Behavior/Violence:______
Fire Setting:______
(IX) Activities of Daily Living
Independent; Needs moderate support; Needs significant support
(X)Previous RRP involvement? Yes____ No _____ If yes, reason for discontinuation of RRP
Consumer preference of provider ______
Cultural preference of consumer ______
(XI)Rationale for Service:
(Please include major areas of need and applicant’s goals for RRP)
______
______
______
______
______
Recommended Level of Residential Placement:
General Level (General support means staff are available, on-call, 24 hours per day,
7 days a week and provide a minimum of one face to face contact per
individual per week.)
Intensive Level (Intensive support means staff provide daily off-site services in the resident
with a minimum of 40 hours per week up to 24 hours a day, 7 days a
week.)
(RRPs at both levels of care provide on-call availability 24 hours per day.)
(XII)Is the applicant in agreement with the above referral? Y N
If "No", explain :
______
Referral Source Signature Date
Please review application to ensure it is complete and all sections are filled out.
Baltimore Mental Health Systems, Inc.
Residential Rehabilitation Programs (RRPs) in Baltimore City
Description of RRP
Residential Rehabilitation Programs are designed to assist those who have a serious mental illness and are in need of psychiatric rehabilitation in a supervised residential setting (assistance with Activities of Daily Living, community integration, medication monitoring, etc.) There two types of levels available:
General Support- Staff are available on-call 24 hours per day, 7 days per week, and provide at a minimum one face to face contact per individual, per week.
Intensive Support- Staff provide services daily on site in the residence with a minimum of 40 hours per week up to 24 hours per day, 7 days per week.
The housing provided is furnished and supervised by staff. All residents are expected to contribute to the cost of their care. Money for food and personal needs is allotted. Typically, the households are comprised of 2 or more residents. Residents have rights and responsibilities, and each program has their own unique variances to the rules that need to be followed. The residents are responsible for housekeeping. A productive daytime activity is required for residing in RRP. The goal of residential rehabilitation is to work towards independent living.
I have read the description of Residential Rehabilitation above and I understand that:
1. I will be living with others, but have my own room
2. I will be assisted by staff
3. I will be required to follow rules and participate in a day activity or work.
4. I will be required to contribute to the cost of my care.
I wish to apply for the service
______
Client Signature Date
______
Referral Source Signature Date
CONSENT TO RELEASE INFORMATION
FOR RESIDENTIAL PLACEMENT
I give my consent to (CSA)
to release this application and other clinical and psycho-social history to a Residential Rehabilitation Program in order to assess my eligibility for residential services in the community.
I understand that this information will not be released to any other party without my express written consent.
I further understand that my consent does not commit me to accept a placement, and it does not commit the Core Service Agency to provide a placement for me.
I understand that I may revoke this consent at any time by a written statement. This consent is valid for 12 months from the date of my signature.
Signature: Social Security #:______
Date: __ Date of Birth: Witness:______