Metro Crisis Coordination Program - Intake/Referral Form

Please print out these sheets, fill them out and fax them to: MCCP at 612-869-6743 along with the Client’s ISP and Risk Management Plan if applicable.

General Information: Todays’ Date: ______________

Type of Referral: Preventative

(circle one) Emergency

Is this person currently in the hospital? YES NO

Current Funding: MA Regular Waiver

(circle one) MA Crisis Waiver

Consumer Support Grant

Family Support Grant

CDCS

TEFRA

ICF/MR

None

Other __________________

Client Information:

Client Name: ______________________________

DOB: (mm/dd/yy)_________________________

SSN #: _______________________

Address: ____________________________

___________________________________

___________________________________

Phone: __________________________

County of Residence: _____________________

Reason for Referral & Miscellaneous Information: (Please be breif, you can explain in full when you are contacted by the behavioral analyst.)

____________________________________________________________________________________

____________________________________________________________________________________

Referral Contact Information:

Referred By (Your name): ______________________

Relationship: (CM, Guardian, residental provider, etc)_____________________

Phone: __________________________

Other Contact Information:

Conservator Information:

Conservator Name: ____________________________

Relationship: _________________________________

Conservator Phone: ___________________________

Conservator Address: __________________________

_____________________________

_____________________________

Legal Status:

(circle one)

Self

Private

State

Residential Supports:

Type of Support:

(circle one)

SLS

SILS

ICF

Foster

Respite

PCA

In-Home Waivered Service

None

Provider Name: ______________________________

Contact Person: ______________________________

Phone: _____________________________________

Alt. Phone: __________________________________

County Case Management Information:

County of $ Responsibility: ______________________

Case Manager: ________________________________

Phone: _________________ Fax: _____________________

Diagnosis & Medical Information:

MA-PMI #: ______________________

MR Level:

(circle one) Boderline

Mild

Moderate

Severe

Profound

Related Conditions

Primary Psychiatric Diagnosis: ____________________________

Primary Medical Diagnosis: _______________________________

Other diagnosis (if applicable): ____________________________

(circle one of the following in each question)

Seizure Disorder: YES NO

Allergies: YES NO

Daily Living Skills: Independent Needs Assistance Needs Prompts

Communication: Verbal Non Verbal Limited

(please check yes or no for the following)

Previous Psychiatric Hospitalization? YES NO

Previous RTC Placement? YES NO

Is there a Behavior Management Plan? YES NO

Crisis Prevention Plan? YES NO

Rule 40 Program? YES NO

Risk Management Plan? YES NO

On any Psychtropic Meds? YES NO

If so, please list meds (just names, please)

_____________________________________________________

Education/Work Information:

Please cirlce which program client is involved in:

Day Program

Work Program

School

Name of School, Day program, Employer: __________________

Contact person: _________________________

Phone: ________________________________

Type of Work/Activity: _____________________

After this is completed please fax along with the client’s Risk Management Plan and ISP to 612-869-6743, attention: INTAKE

Someone will call you to complete the referral process and confirm information.