Intensive Care Coordination and Wraparound

Referral

(Ages 0-17)

Required Documentation:

Completed Referral Form (page 3)

Mental Health Assessment with ICD-10 Diagnosis within the last 60 days

Current information showing areas of need such as school records, medical records, or behavioral health records or court records

WRAPAROUND ONLY

Wraparound Review Committee Consent Form (page 4)

Wraparound Presentation Form (page 5)

Family, current providers and system partners should all be aware of and in support of the referral for Intensive Care Coordination and/or Fidelity Wraparound prior to submission of the referral.

Send Completed Referralsby mail, fax, or email to:

FamilyCare Health

Behavioral Health Intake

825 NE Multnomah Blvd.

Suite 1400

Portland, OR. 97232

Phone: (503) 222-2880

Fax: (503) 345-5754

E-mail:

REFERAL REQUEST

____Wraparound____Intensive Care Coordination____Unsure

  • Intensive Care Coordination: Assists children, families and young adults with the highest need in and out of intensive community and facility based programing through our care planning. This approach is family and youth driven, strengths based, and culturally and linguistically appropriate. Intensive Care Coordination includes phone, face to face and community contactshort-term for a period of 3-9 months.
  • Fidelity Wraparound: Available to our members with the highest level of need, multi-system involvement, elevating risk and/or complex needs for family/members who are interested in the intensive, fidelity based planning process. Wraparound occurs in four phases with structuredmeeting facilitation components at monthly team-based meetings for up to 18 months on average. For additional information, please visit our website: Family, current providers and system partners should all be aware of and in support of the referral for Fidelity Wraparound prior to submission of the referral.

***If you are unsure what type of care coordination to refer for, please contact the Behavioral Health Intake Care Coordinator at 503-222-2880 or

MENTAL HEALTH SERVICES REQUESTS

If you have a request for authorization for Intensive Mental Health Services, please fill out and submit the Mental Health & Chemical Dependency Authorization request form on our website at For questions or assistance, please contact 503-222-2880.

Child, Family and Young Adult Services Array: This service array includes higher levels of behavioral health services such as Intensive Community Based Treatment Services (ICTS), Psychiatric Day Treatment Services (PDTS), or Psychiatric Residential Treatment Services (PRTS) and additional exceptional services.

REFERRAL FORM

Date of Referral: ______

REFERRAL CONTACT

Referred By: / Agency/ Role
Phone: / Fax or Email:

YOUTH INFORMATION

OHP #:
Other Health Insurance: YesNoIfyes,otherinsurancecarrier:
Youth Name: / Date of Birth: / Age:
Ethnic or Racial identity: / Gender:
Primary Language: / Interpreter Needed: YesNo
Parents/Caregiver:
Phone: / Email: / Fax:
Address:
Physical Address of youth (If Different):
Phone: / Fax or Email:
Legal Guardian:
Phone: / Fax or Email:

SYSTEMS AND SUPPORTS INFORMATION

Primary Care Provider:
Phone: / Fax or Email:
Current Mental Health Provider: / Therapist:
Phone: / Fax or Email:
Current School: / IEP: YesNo / Grade:
School Contact: / Phone & Email:
Other Involved Supports: / Role:
Phone: / Fax or Email:
Other Involved Supports: / Role:
Phone: / Fax or Email:
Other Involved Supports: / Role:
Phone: / Fax or Email:
Other Involved Supports: / Role:
Phone: / Fax or Email:

ANTICIPATED NEEDS AND OUTCOME OF REFERRAL (include additional page if needed):

WRAPAROUND REVIEW COMMITTEE CONSENT FORM

I understand that my youth was referred to FamilyCare Wraparound:

Name: ______Date of Birth: ______OHP Member ID#:______

To get started, a screening needs to take place through the Wraparound Review Committee with your consent.

I understand that the screening process may include a complete review of needs, supports, records, and agency involvement from those systems listed below. I also understand that the Wraparound Review Committee may include a representative from each of the following systems:

Educational School District,

Developmental Disabilities,

Juvenile Justice,

Oregon Youth Authority,

Primary Care Physicians,

Behavioral Health Provider,

Department of Human Services/Child Welfare,

Family Representative from Oregon Family Support Network (OFSN) and/or National Association for Mental Illness (NAMI)

I understand that participation in the Wraparound screening process is voluntary and by signing below I give my permission for my youth to participate.

Initials:

______I consent for my youth to be referred to and screened by the Wraparound Review Committee

______I do not consent for my youth to be referred to and screened by the Wraparound Review Committee

______

Member signature (if over 14years of age):Date:

______

Legal Guardian signature:Date:

I understand that all information will be kept private, unless I sign a Release of Information Form. Health information is protected by federal and state law and by FamilyCare, Inc. policy. I also understand that I can withdraw my consent at any time.

Contact the Behavioral Health Intake Department if you have questions at: (503) 222-2880.

WRAPAROUND PRESENATION FORM

Date:

Name: DOB: Age: Gender:

OHP #: CCO:

Legal Guardian: Residence: Legal Parent/Guardian:

Foster Home:

Residential:

Other:

Current System Involvement

Individualized Education Plan: Yes No 504 Plan: Yes No

Juvenile Counselor/OYA:

Mental Health Provider:

Physical Health Provider:

Developmental Disabilities Coordinator:

DHS Child Welfare Worker:

Reason for Referral for Fidelity Wraparound Planning Process:

Current needs addressed by the Wraparound planning process?

How will the youth/family benefit from the Wraparound planning process?

Is the youth/family interested in and what do they understand about Wraparound?

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