PM FORM 3.3.1

Referral for Behavioral Health Services

FAX TO: 866-616-8773

Follow up by phone: 844-882-5354

I.Information on Person Making Referral

Today’s Date / Time (24 hour clock)
Name and Title: / Title
Affiliated Agency: / Phone: / Fax:
Type of Service Requested: / One Time Consultation / Ongoing Behavioral Health Services
Behavioral Health Services Requested (check all that apply)
Treatment Services / Rehabilitation Services
Medical Services / Support Services
Behavioral Health Day Programs

II.Information on Person Being Referred for Services

F / M
Last Name / First Name / DOB / Gender
Marital Status: / Single / Married / Divorced / Widowed / Primary Language
Address / City / State / Zip / Telephone
Current location (if other than above) / Cell Phone:
Parent/Legal Guardian (if applicable) / Phone:
Identify individual(s) the member, parent or guardian may wish to be invited to initial appointment with person(include phone).
Person/Parent/Guardian is aware of referral: / No / Yes
Cultural and language considerations? / No / Yes / If yes, specify language/need
AccommodationNeeded for:
Mobility / No / Yes / If yes, identify assistance needed
Visual Impairment / No / Yes / If yes, identify assistance needed
Hearing Impairment / No / Yes / If yes, identify assistance needed
Developmental/Cognitive Impairment / No / Yes / If yes, identify assistance needed
Payment Source:
AHCCCS ID# / Self Pay / Medicare / Other:
Private Insurance / Private Insurance/Health Plan Name
PCP: / Phone: / Fax:

Check any of the following which pertain to the person being referred:

Shows evidence of suicidal or homicidal thoughts or behaviors / Was recently D/C from inpatient setting
Other potential risk factors, e.g., dehydrated, malnourished, homeless / Children in CPS custody
Pregnant Woman / Has immediate medical needs
Pregnant w/substance abuse / IV drug user
Identified need for psychotropic medication / Is currently hospitalized.
Reason for Referral:
Additional information and contact information.
If the person is taking medications to treat a behavioral health condition, does she/he have an adequate supply for the next 30
days?YesNo If no, when will she/he exhaust the current supply of medication?
Referral Received:
Last Name: / First Name: / SSN:
Name and Title:
Affiliated Agency: / Phone: / Fax:

The following information is to be completed by the Network Provider

III.Unable to contact person being referred

Number of outreach attempts

Type of Outreach and Engagement conducted (check all that apply)

Phone Calls / Number of Calls / Face to face visit attempt / Number of attempts

If unsuccessful, state reason why (check all that apply)

No answer to phone call(s) / Person being referred already enrolled in behavioral health services
Telephone disconnected / Person being referred refuses behavioral health services
Message(s) left with no response
Referral source notified of unsuccessful contact; if this box checked, list alternate contact information obtained:

IF UNABLE TO CONTACT – STOP HERE

Date Received: / Time (24 hour clock)
If applicable, name and contact information of the provider that will assume primary responsibility for the person’s behavioral
healthcare:
Type of appointment: / Immediate / Urgent / Routine
Available Intake Appointment Offered (specify date, time, place)
IV. Action Taken
Scheduled Intake Appointment (specify date, time, place):
Not referred for appointment (specify why)
Other disposition, explain
V. Outcome (within 30 days)
Intake appointment kept / Yes / No
If no, why? (check all that apply):
Rescheduled by provider / Rescheduled by person being referred
Cancelled without rescheduling by person being referred / Person being referred was a “no show”
Was the assessment done on same day as intake? / Yes / No
If no, date assessment schedule for:

Return to Referral Source and AHCCCSBehavioral Health CoordinatorwithAction Taken Section complete.

Fax #s for Health Plan BH Coordinators:

American Indian Health Plan: / 602-417-4471 / Health Choice: / 480-760-4764
Care 1st: / 602-778-1838 / Mercy Care Plan: / 800-873-4570
DCS/CMDP: / 602-351-8529 / University Family Plan: / 520-874-3411
United Healthcare: / 855-239-6158

PM Form 3.1.1 Page 1 of 2

Last Revised: 2/3/2016

Effective Date: 10/1/2015