Lehigh county mental health/ mental retardation/ drug & alcohol

ASSERTIVE COMMUNITY TRETMENT (ACT)
REFERRAL PACKET
THE REFERRAL PROCESS
Referrals to Assertive Community Treatment (ACT) teams will be accepted from professionals/providers of treatment and/or any other agency/hospital involved in the provision of Human Services. Individuals who are not enrolled in Magellan Behavioral Health services must be submitted to their county of residence (Lehigh or Northampton) for approval. The counties will than forward the referrals to the ACT provider. ASSERTIVE COMMUNITY TREATMENT – CRITERIA FOR ELIGIBILITY

PART 1: Must meet ALL the Criteria in Part 1 to be eligible for ACT

Diagnosis: Primary diagnosis of schizophrenia or other psychotic disorders such as schizoaffective disorder, or bipolar disorder as defined in the DSM IV-R. Individuals with a primary diagnosis of substance use disorder, mental retardation, or brain injury are not the intended consumer group Difficulty utilizing traditional cases management or office based outpatient services or evidence that they require more assertive and frequent non-office based service to meet their clinical needs
Functional level: Current GAF 40 or below Current GAF:
PART 2: Must meet two (2) out of the six (6) criteria in Part 2 to be eligible for ACT (Check (9) if “yes” )

Two psychiatric hospitalizations in the past 12 months or lengths of stay totaling over 30 days in the
past 12 months Intractable (persistent or very recurrent) severe major symptoms (affective, psychotic, suicidal) Co-occurring mental illness and substance use disorders more than six (6) months duration at the time of contact High Risk or Recent history of criminal justice involvement which may include frequent contact with law enforcement personnel, incarcerations, parole or probation Literally homeless, imminent risk of being homeless, or residing in unsafe housing Residing in an inpatient or supervised community residence but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring residential or institutional placement if more intensive services are not available ASSERTIVE COMMUNITY TREATMENT
ADMISSION REFERRAL FORM

Note: This form must be completed in its entirety and submitted with ALL supportive documentation:
Psychiatric Evaluation, Copy of Current MA Card, Treatment History, Psychosocial History, GAF, a copy
of Recent Lab Results, recent Progress Notes and any other documentation which will support the
consumer’s eligibility for Assertive Community Treatment team services. Whichever criteria the consumer
meets must be supported by documentation or the referral will be incomplete and the assessment will not
occur.
Date of Referral
Sex (circle one) Male Female Age: ______ Date of Birth: ____________ Social Security Number: Medical Assistance: Recipient Number ______________ If Currently Hospitalized: Name of Hospital: __________________________ Date Admitted: ____________
Social Worker: ______________ Telephone: _____________ Projected D/C Date:
Interested Family Member or Friend: Name(s) ________________________________________ Address: ________________________________________ Telephone Number: _______________________________ Has This Referral Been Discussed With the Consumer Current Diagnosis: Axis I _______________________________________ II _______________________________________ III _______________________________________ IV _______________________________________ V _______________________________________ Psychiatrist: _____________________Address: ___________________ Telephone: __________ Community and State Hospital Admissions {List/Date any hospitalizations within the last 12 months}: ________________________________________ __________________________________ ________________________________________ __________________________________ ________________________________________ __________________________________ Current Medications/ Dosages/ Frequency: Requires Monitoring: ___ Yes ____No ________________________________________ __________________________________ ________________________________________ __________________________________ ________________________________________ __________________________________ ________________________________________ __________________________________ Allergies: Medication/ Substance _________________________ Reaction: ________________ Clozaril Treatment { if applicable }: Date began treatment: ________________________ Where: __________________________ Present Treatment Facility: ____________________ Dosage: ________________________ How is Clozaril being monitored at present? _________________________________________ Primary Physician: __________________ Address: _____________________ Telephone: ________ Dentist: ___________________________ Address: _____________________ Telephone: ________ Neurologist: ______________________ Address: ______________________ Telephone: ________ Other Doctor: _____________________ Address: _______________________ Telephone: ________ Current Medical Condition (Acute or Chronic medical problems). Current medications for medical problem, and family history of/or current medical problems: Is there any current involvement with mental health services? Total Number of State Hospital Admissions: List prior treatment facilities (out-patient, partial hospitalization, etc…include outcome and consumer’s participation): Substances Used (frequency, evaluations, treatment, and treatment effectiveness for both family and consumer): Has SSI/SSD/MA Application been started? Other sources of income (include any Bank Accounts or Life Insurance Policies): If Yes: Name: ___________________________ Address: _____________________________ Relationship: ______________________ Agency: ____________________________ Does individual have a secure living arrangement? If No, where is the individual currently living? Describe any problems with past living arrangements? { ex. Past due rent, property damage, etc.} Where would the individual prefer to live? Are these living arrangements possible/available? Are there any family supports available? Any family history of Mental Illness? _________ Yes _________ No If Yes, who ___________ Any Criminal/Legal History? ________ Yes _________ No ________________________________________________________________________________ History of behaviors {include when, toward whom, and if weapons were involved}: Assaultive/ Aggressive ________________________________________________________ Homicidal __________________________________________________________________ Suicidal ____________________________________________________________________ Physical Abuse ______________________________________________________________ Sexual Abuse _______________________________________________________________ Fire Setting ________________________________________________________________ Completed Grade Level: _______ Any College or Vocational Programs? __________________ Currently Employed? ______Yes _______No If Yes, Where ___________________________ ______Part-Time _____Full-Time ______________ Hours/Days working Other relevant information about individual being referred for ACT and their need for ACT services? Name of Person Completing Referral: __________________________________
Agency/Hospital: _____________________________
Date: _________

Source: http://www.magellanofpa.com/media/156457/act%20referral%20(3).pdf