CSS I-START Consultation Referral Form
Client Name: Click here to enter nameDate of Birth: Click here to enter DOB
Date of Referral: Click here to enter referral date
Race/Ethnicity: Click here to enter information
Primary Language: Click here to enter information
Gender: Click here to enter information
Legal Guardian: Click here to enter information
County of Residence: Click here to enter information
CSN ID: Click here to enter information
Address and Phone Number
Street 1: Click here to enter address
Street 2: Click here to enter address
City, State, Zip: Click here to enter city, state, zip code
Phone Number:Click here to enter phone #
Referred by
Name & Title: Click here to enter name
Area Agency: Click here to enter name
Phone Number: Click here to enter phone #
Email Address: Click here to enter address
DSM Diagnoses: (DSM IV or DSM V without Axis information)
I. Click here to enter axis I information
II. Click here to enter axis II information
III.Click here to enter axis III information
IV.Click here to enter axis IV information
V. Click here to enter axis V information
Individual’s Team Contact Information
Contact Name / Relationship / Email Address / Phone NumberFamily
Guardian (if different than family contact)
Residential Provider
Day Program Provider
Case Manager
Primary Care Physician
Psychiatrist
Counselor/Therapist
Other:
Other:
Other:
It is critical for our team to have all of the following questions answered in depth so we are able to properly develop an individualized, multi-disciplinary approach to each referral.
1)Reason for Referral: (concerns/issues/presenting problem/onset/duration)
Click here to describe what you would like from consultation services, please be specific
2)Medical Issues/Illnesses:
Click here to enter medical information
3)Service history for the past 5 years,including all types of hospitalizations,all residential and/or institutional placements, and any time served in jail.
Date(begin with current) / Name of Service Provider/Agency/Hospital/etc. / Outcome/ResultClick here to enter a date / Click here to enter name / Click here to enter outcome /
Click here to enter a date / Click here to enter name / Click here to enter outcome /
Click here to enter a date / Click here to enter name / Click here to enter outcome /
Click here to enter a date / Click here to enter name / Click here to enter outcome /
Click here to enter a date / Click here to enter name / Click here to enter outcome /
Click here to enter a date / Click here to enter name / Click here to enter outcome /
Click here to enter a date / Click here to enter name / Click here to enter outcome /
Click here to enter a date / Click here to enter name / Click here to enter outcome /
Over the last year, how many times have the following been used to assist this individual?
- Adult Crisis StabilizationCenter:Click here to enter times used
- Emergency Department:Click here to enter times used
- Law Enforcement/Emergency Dispatch:Click here to enter times used
- PsychiatricHospitalization:Click here to enter times used
- Other: Click here to enter times used
4)Psychosocial Well-Being:
a)Emotional upsets/significant issues/areas of concern: Click here to enter information
b)Recent changes in social functioning: Click here to enter information
c)Concerns with expectations and support: (day program/residential/recreational)Click here to enter information
d)Changes or concerns re: eating, sleeping, toileting, mood from baseline:Click here to enter information
e)Skills and abilities: Click here to enter information
f)List behavior signs or symptoms of concern: Click here to enter information
g)Describe how the individual was doing when he/she was at his/her best (include medications, services, date and description of presentation):
Click here to enter description
Presenting Concernsat Time of Referral (check all that apply):
☐Aggression (physical, verbal, property destruction, threats)
☐At risk of losing placement
☐Decreased ability to participate in daily functions
☐Diagnosis and treatment plan assistance
☐Family needs assistance
☐Leaving unexpectedly
☐ Self-injurious
☐Sexualized behavior
☐Transition from hospital
☐Mental health symptoms
☐Suicidal ideation/behavior
☐Other: Click here to identify other
Services at Referral (check all that apply):
☐Vocational/prevocational services
☐Employment services
☐Day services/program
☐Respite services
☐Behavioral support services
☐Case management/service coordination
☐Mental health outpatient services
☐Enhanced staffing (1:1 or 2:1 staff)
☐Employed: If yes, click here to describe
☐Other:Click here to identify other
FundingSource (check all that apply):
☐ID Waiver
☐BI Waiver
☐HCBS Habilitation
☐MedicaidIf yes, indicate which MCO
☐Medicare
☐Private Insurance
☐None
☐Other: If yes, click here to describe
Additional Section (18 & under):
Grade in School: Click here to enter informationCurrent IEP: Click here to enter information
Current 504: Click here to enter information
School Setting: Click here to enter information
Custody Status: Click here to enter information
Child Lives with: Click here to enter information
Iowa Rules require CSS to track the following outcome measures regarding the individualswe support. Please put checks in the boxes below that are most accurate for each outcome. In some cases more than one outcome could apply.
Housing: Are you residing in safe, affordable, accessible housing? / Homeless / In Placement / Staying w/friends or family / Housed / Safe? Yes NoAffordable? Yes No
Accessible? Yes No
Medical Care: How often do you see a primary care physician? / Never / Less than once a year / Once a year / More than once a year / If never or less than once a year, why?
Employment: Are you successfully employed? / Unemployed / Sheltered Work / Supported Employment / Community Employment / Hourly Wage: $______
Hours / Week ______
Community Integration: Are you participating in integrated community activities? / Clubs/ Social Groups / Church / Community Activities/Events / Volunteer / Other : describe
______
Please send completed form, along withthe following pertinent records to or fax to 641-201-3992.This requested documentation is essential to our multi-disciplinary team as we review each referral prior to the Coordinator setting up an intake/assessment with the client’s existing team of support.AnI-START team member will be in contact with you in two business days of referral submission.
Recordsinclude but not limited to:
☐Current ICP
☐Current Medication List
☐Current Social History
☐Current Assessments
☐Any Behavioral Plans
☐Any Clinical Reports, Consultations and/or Case Summaries
☐Guardianship Papers, permission granted prior to referral to program
In addition, if you are someone who has access to CSN, please ensure the individual has a completed Level I CSS Intake Application. If not please complete and submit to Central Intake at . If the Level I is over a year old, please update the application and submit to Central Intake at .
We look forward to collaborating with you regarding this referral!
Thanks,
CSS I-START Team