Free 52179.FH11 - Indiana

STATE HOSPITAL REFERRAL

Date of referral (month, day, year) Update (month, day, year)

State Form 52179 (R / 1-07) / CS 0020 FAMILY AND SOCIAL SERVICES ADMINISTRATION DIVISION OF MENTAL HEALTH AND ADDICTION

Mark all State Operated Facilities (SOFs) receiving

EPCC
Preference

ESH ESH

MSH MSH

LCH LCH

RSH RSH

LSH LSH

EPCC

PATIENT INFORMATION
Name of patient (last, first, middle, maiden) Home address (number and street, city, state, and ZIP code) Telephone number Primary language Previous SOFs Marital status Date of birth (month, day, year) Social security number Sex County

Male Female

(

)

Married Divorced

Single Widowed

Commitment status

Temporary commitment Extended temporary
If yes, list county:

Regular commitment Commitment pending
Explain:

ICST Voluntary

Date of commitment (month, day, year)

County of commitment

Any outstanding legal charges?

Yes
LOC for MR/DD

No
Date of expiration (month, day, year)

Yes
Check if

No Custodial Parent
Relationship

Health Care Representative
Name Home address (number and street, city, state, and ZIP code) Type of insurance

Legal Guardian
Telephone number

(

)

Insurance number(s)

Medicare
Financial resources and amounts

Medicaid

Other
Payee

SSD $________
Name of payee

SSI $________

VA $________

Other $________

Self

Other

Address (number and street, city, state, and ZIP code)

PSYCHIATRIC INFORMATION
Current placement Address (number and street, city, state, and ZIP code) Diagnosis - Axis I GAF - past 12 months Current symptoms and behaviors - any changes: Diagnosis - Axis II GAF - current Diagnosis - Axis III IQ (MR/DD) Date admitted (month, day, year)

Brief history (presenting problems / risks including self harm, aggression, elopement, falls):

Current medications and dosages

Recent medication changes - why?

TREATING PHYSICIAN
Name of physician Telephone number

(
MEDICAL NEEDS / SPECIAL NEEDS

)

Diet Mobility Hearing Impairment Visual Impairment Communication Difficulty Allergies Past History of T.B. PPD - Results ______________________

Communicable Disease Medical Equipment Circulatory Issues (Heart Disease, HTN, etc.) Respiratory (COPD, asthma) GI Tract (ulcers, gastric reflux, colostomy G-tube, etc.)

GU Tract - Urinary (dialysis, incontinence, catheter, etc.) Diabetes Neurological (seizures, NMS, altered gait) Diabetic Suicidal Assaultive

Explain any items checked above and current treatment, if applicable. Copy of current physical may be used if current treatment is included. Attach additional sheets if necessary.

Expectations of hospitalization and anticipated length of stay specific and measurable goals for community reintegration:

GATEKEEPER / DISCHARGE PLAN - COMMUNITY PLACEMENT NEEDS
Assigned Gatekeeper Hospital Liaison Address (number and street, city, state, and ZIP code) Signature Date (month, day, year) Telephone number

(

)

SGL (24m) SMI/SA/SED SGL (24m) MR/DD Supported Living - MR/DD only ICF/MR Facility - MR/DD only Family Personal Home

Specialized Residential Facility Medical or Nursing Facility Cluster Apt. Setting or SILP DOC (forensic only) Locked or Subacute

RBA Halfway Program - Chemical Addiction AFA Therapeutic Foster Care Other: _____________________________

GATEKEEPER / DISCHARGE PLAN - POST SOF PROGRAM NEEDS Day Treatment / Partial Hospitalization Intensive Outpatient Medication Evaluation & Monitoring Case Management Substance Abuse Aftercare Vocational & Employment Services ACT Assertive Community Treatment IDDT - Integrated Dual Diagnosis Treatment SOC - Systems of Care (SED) Childrens Medicaid Waiver Recreational Therapy - MR/DD only Behavioral Modification & Support - MR/DD only Community Habilitation - MR/DD only Health Care Coordination - MR/DD only Prevocational / Sheltered Employment MR/DD only Other: _______________________________ _______________________________

STATE HOSPITAL REFERRAL DIRECTIONS
When admission to a state hospital is determined appropriate by the Gatekeeper, the State Hospital Referral Form is to be completed, signed by the Gatekeeper, and forwarded to the appropriate state hospital with the documents as listed below. Upon receipt of the form and required documents, the state hospital will contact the Gatekeeper within two working days regarding service / bed availability / waiting list. The following documents are required with the Admission Referral Form: Current mental status (most recent psychiatric assessment) and significant findings Current risk factors (self-harm, aggression, elopement, falls, etc.) Most recent physical examination Any pertinent medical workups Commitment papers (or as soon as available; must be prior to admission) Legal papers (guardianship, wardship, legal charges, etc.) Current treatment plan (include current medications with dosages) Current psychological testing scores if available Exceptions are: Result of TB test (date given and read). Test preferred within thirty (30) days, but required within ninety (90) days prior to admission Additional documentation is required for MR/DD and Child/Youth Referrals with the Admission Referral form: MR/DD Referrals Diagnostic and Evaluation DD Eligibility if Determined BDDS Involvement CMHC Screening School History and Education (IEP if available) Psychological testing scores and person/place to contact Child/Youth Referrals - SED Waiver Enrollment Immunization School History & Education, Records & IEP (psychoeducational evaluation, if possible) History of Past Treatment Birth Certificate Institutional Level of Care The Admission Referral Form must be submitted again at the time of admission to the state hospital. Only those sections noting changes since the referral (medication changes, legal changes, etc.) must be completed. This is to insure that the state hospitals have current information at admission. If the patient information remains the same as at the time of submission of the referral packet, you must submit the admission referral form again and indicate in the Update box, No Changes. DMHA will be implementing a monitoring form to be used by admission staff at the state hospitals.