INTENSIVE IN-HOME PROGRAM
Referral/Client Screening Form
Referral Date: Referring Staff Name:
Referring Agency: Referring Agency Address:
Referral Phone Number: Referral Fax Number:
Case Manager: Phone Number:
Client Name: Client Address:
Client Phone Number: Client SS#:
Client DOB: Client Age: Client Race: Client Gender: M F
Client Medicaid Number: Other:
Client Legal Guardian Name (if applicable):
Guardian Address: Relationship to Client:
Guardian Phone Number(s):
Presenting Problem/Needs/Preferences (psychiatric, medical, current medications & history of medical care):
Intensive In-Home Eligibility Criteria
Recipients of Intensive In-Home (IIH) Services must have the functional capability to understand and benefit from the required activities and counseling of this service. These services are rehabilitative and are intended to improve the client’s functioning. It is unlikely that individuals with severe cognitive and developmental delays/impairments would clinically benefit and meet the service eligibility criteria.
Children and adolescents must demonstrate a clinical necessity arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities.
Individuals must meet at least two of the following three criterion on a continuing or intermittent basis:
Yes No Does the child have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community?
Yes No Does the child exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary?
Yes No Does the child exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior. For example: is at risk for acting out in such a fashion that will cause harm to themselves or others.
Yes No Is the child at risk for Out-of-Home placement to Level A or Level B group home, regular foster home, treatment foster care, Level C residential facility, emergency shelter (due to MH/behavior problems), psychiatric hospitalization, or juvenile justice/incarceration placement?
Referring Individual’s Signature Date
Please note USS will retain this information for a period of six months for those individuals who are not admitted for services. For individuals admitted for services, this documentation will be kept in the individual’s case record.