ࡱ>  {+bjbjUU 0X??U#%rr8deT#."<P \"""""""$5$&~"@<"W"""b  `;gz r""0# ,U'[U' U' dx Sddd""ddd#U'dddddddddr {:  INCLUDEPICTURE "http://www.njleg.state.nj.us/kids/decor/state-seal2.jpg" \* MERGEFORMATINET  STATE OF NEW JERSEY Department of Human Services Division of Mental Health Services Agency Referral and Response Form I. Identification and Submission to Agency (completed by Hospital Placement Entity and submitted to Agency): Date Submitted to Agency________________ Agency Contact______________________________________________ Agency Name: _________________________________________________________Level of Housing___________________ Agency Address _________________________________________________________________________________________ Type of Residential Service Requested:  FORMCHECKBOX  RIST  FORMCHECKBOX  Supportive Housing  FORMCHECKBOX  Supervised Residential Services  FORMCHECKBOX  Other (specify)________________________________________________________________________________________________ II. Treatment Team Request (completed by Social Worker and/or Placement Entity): Consumer Name:_______________________________________________ DOB:__________________________________ Unit/Location:____________________________________________________________________________________________ Admission Date:__________ CEPP Date:__________ Social Worker Name: ______________________________________________________________________________________ Phone:________________________________________________ Fax:____________________________________ Email: ___________________________________________________________________________________________________ A. CLINICAL DISCHARGE READINESS (Explain): 1. Psychiatric Stability (i.e.., not currently dangerous to self/others):   _________________________________________________________________________________________________________ 2. Motivation for Discharge (i.e., consumer readiness for placement)    B. RECOMMENDED LEVEL OF SERVICE (Explain): 1. Clinical/Medical and number of hours required per day of residential supervision ( if any): Service specific skill/ functioning level (include medical concerns, dual diagnosis needs, medication adherence, and skill deficits, etc):    ________________________________________________________________________________________________________ 2. Other: Financial, benefits, legal, birth certificate, social security card, immigration status:   Evaluation Packet Enclosed:  FORMCHECKBOX  (psychosocial assessment, psychiatric assessment, physical assessment, psychological if available, judiciary involvement, family/emergency contact information, medication order sheet, progress notes x 2 weeks). Consumer is or will be followed by:  FORMCHECKBOX  ICMS  FORMCHECKBOX  PACT  FORMCHECKBOX  RIST  FORMCHECKBOX  Supportive Housing C. AGREEMENT: Consumer is in agreement with discharge and discharge plan  FORMCHECKBOX  yes  FORMCHECKBOX  no If no, please explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________ I verify that the preceding information is accurate and that the accompanying referral packet includes all necessary components. ________________________________________________________________________________________________________ Hospital Placement Entity Signature Phone Number Date III. a. Agency Response (completed by Agency and submitted to Hospital Placement Entity) **Response requested within five (5) business days of receipt of referral) Date returned to SW: _____________________ Accepted:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Agency Name:_____________________________________________________________________________________________ Contact person: ___________________________________________________________________________________________ Phone: _________________________________________ Fax: ____________________________ Date of Initial Consumer Interview:__________________ Date of Proposed BV (If applicable):______________________ Proposed Discharge Date and Time: _______________________________________________ Comments and recommendations for discharge preparation: ________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ IF NO, Explanation and Recommendations from agency:________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ A. CLINICAL DISCHARGE READINESS (explain): 1. Psychiatric stability (i.e., not currently dangerous to self/others):    _________________________________________________________________________________________________________ 2. Motivation for Discharge:    B. RECOMMENDED LEVEL OF SERVICE (explain): 1. Clinical/Medical Needs & Number of Hours Required per Day of Residential Supervision (if any):    _________________________________________________________________________________________________________ 2. Other: Financial, benefits, legal: _________________________________________________________________________________________________________   III.b. Consumer Response (completed by consumer and agency) Consumer agrees with discharge placement Yes No Consumer Comments and Recommendations: __________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ IV. Treatment Team Response to Recommendations (completed by Social Worker) Date reviewed by Treatment Team ___________________ IF AGREE, Summarize Treatment Team Plan: _______________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ A. CLINICAL DISCHARGE READINESS (Explain): 1. Psychiatric Stability (i.e.., not currently dangerous to self/others):   _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 2. Motivation for Discharge (i.e., consumer readiness for placement)   _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ B. RECOMMENDED LEVEL OF SERVICE (Explain): 1. Clinical/Medical Needs & Number of Hours Required per Day of Residential Supervision (if any):    2. Other: Financial, benefits, legal:   _________________________________________________________________________________________________________ IF DISAGREE, attach additional comments__________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ V. Agency Response Additional Information (completed by Agency and comments submitted on additional pages): __________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Date returned to Director of Social Services at Hospital, Program Analyst and Regional Olmstead Team: ________________ VI. Disposition: Date__________________ Accepted:  FORMCHECKBOX  Yes  FORMCHECKBOX  No (explain):  _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Date returned to Treatment Team (Social Worker to file in chart) ____________________ Rev. 3/30/11     PAGE  PAGE 1 ^_`abcw  . 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