Download Outreach Services Request and Referral Form

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Phoenix Counseling and Crisis Centers
Outreach Services Overview
Our Outreach Team currently offers three services, below are basic descriptions of these services. Our
Outreach specialist will match the most appropriate service with the consumer’s current needs.
Peer Support Services (B3) Description:
Peer Support Services are provided by Peer Support Specialists, which are individuals who themselves are in recovery from MH and/or SA
issues. Peer Support Services is an individualized, recovery-focused service that allows individuals the opportunity to learn to manage their
own recovery and advocacy process. We aim to enhance the development of natural supports, as well as coping and self-management skills.
Our Peer Support Specialists value and emphasize personal safety, self-worth, confidence, and growth, connection to community, boundary
setting, planning, self-advocacy, personal fulfillment, and development of social supports, and effective communication.
Basic Criteria:
· Adults 18 y/o and up
· Must have active NC Medicaid that originates from one of the following counties: Gaston, Lincoln, Cleveland, Burke, Catawba, Iredell,
Surry, or Yadkin.
· Current mental health and/or substance abuse diagnosis/condition.
· The individual must be willing to receive services from our Peer Support Specialists, services can be delivered in a variety of settings (i.e. The
community, in office, or in a group setting).
Peer Support Aftercare & Diversion Services Description:
Peer Support Aftercare & Diversion Service aims to engage individuals in treatment following a period of hospitalization or incarceration
(including Black Mountain, detox facilities, & jail/prisons) and bridges the service gap when timely aftercare is unavailable. This service also
aims to divert individuals from re-entry into inpatient behavioral health facilities, jails, and prisons.
Basic Criteria:
· Adults 18 y/o and up
· Current mental health and/or substance abuse diagnosis/condition.
· Discharged from an inpatient behavioral health facility, jail, or prison within the past 45 days; OR in crisis; OR at risk of needing inpatient
behavioral health treatment.
· The individual must be willing to receive services from our Peer Support Specialists, services can be delivered in a variety of settings (i.e. the
community, in office, or in a group setting).
Assertive Engagement Service Description:
Assertive Engagement is a way of working with adults and/or children who have severe mental illness and/or substance use disorder and
have difficulty engaging in treatment services. Assertive engagement is a critical element of the rehabilitation and recovery model as it
allows flexibility to meet the consumers’ particular needs in their own environment or current locations. The goal is for the individual to
receive timely outreach and engagement into the most appropriate community based treatment.
Basic Criteria:
· This service is for individuals who do not have Medicaid, Medicare, or private insurance benefits.
· Complex mental health, substance use, and/or intellectual/developmental disability diagnosis/condition.
· Currently has significant therapeutic disconnect (including a history of erratic engagement or non-compliance with treatment services and
prescribed medication).
· History of frequent and/or repeated crisis episodes , especially multiple emergency department admissions.
· History of readmissions to inpatient behavioral health settings (community & state hospitals, detox, facility based crisis, PRTF, etc.)
· History of involuntary commitments.
· Involved with the criminal justice system and due to mental illness/substance use have been repeatedly arrested and/or incarcerated.
Please submit referrals to our Outreach Specialist:
Dawn Taylor, BA QP
2505 Court Drive
Gastonia, N.C. 28054
(Office) 704-842-6396
(Work Cell) 704-860-0823
(Fax) 704-884-2052
(Email) [email protected]
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Outreach Services Request and Referral Form
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Outreach Services Request and Referral Form
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Phoenix Counseling and Crisis Centers
Outreach Services Request and Referral Form
Date: ___________________ Time: ______________________
1. PRIMARY REFERRAL SOURCE INFORMATION
Referring Agency:
Hospital Name: ____________________
CCNC
DSS County: ____________
Other: ___________________________________________________________________________________
Provider Agency:
_______
Phone #:_______________ Fax #:____________________________
Agency Contact Person:___________________________ Phone #____________________________________
Address: _____________ ____________________City/State/Zip: _____________________ _____________
2. Consumer Demographic Information
First Name: _______________________ Middle Name:_____________________ Last Name:___________________________
Suffix:_________________Maiden: __________________________ Social Security Number: __________________________
Date of Birth:____________________Medicaid Number:_________________________ County: ________________________
IPRS (No Insurance)
Consumer’s Current Address: __________________________ ____________________________________________________
Other Locations Consumer Can Be Found:___________________________________________________________________
Consumer’s Phone Number:_______________________ Other Number:_____________________________________________
Current Living Arrangement:________________________________________________________________________________
3. GUARDIAN INFORMATION (if applicable)
Legal Guardian _________________________________________________________________________________
Relationship: ____________________________________County of Legal Custody: ________________________
Guardian’s Address: ___________________________________________________________________________
Guardian’s Phone Number:______________________________________________________________________
If a Guardian ad Litem has been appointed please list Name and contact number:______________________________
______________________________________________________________________________________________________
Outreach Services Request and Referral Form
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4. REASON FOR REFERRAL/CRITERIA MET
5. Mental Health Information
Most recent DSM IV diagnosis: Date: __________________ By whom? _________________ _______________________
(Use words, not code numbers.)
Axis I:
Axis II:
Axis III (Medical conditions):
Axis IV (Environmental stresses):
Axis V (Current Global Assessment of Functioning): ______
List Current Symptoms:
Anxiety
Hallucinations
Harm to Others
GAF (Highest level in past year): ______
Delusions
Property Destruction
Depression
Agitation
Self Harm
Inappropriate Sexual
Behavior
Unkempt
Unable to Attend to ADL’s
Describe Symptoms:
Current Psychiatric Medications, Dosage, Frequency, and Prescriber:
MR
Other ______________________
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6. Professionals Involvment:
Primary Care Physician: ________________________________ Phone #:___________________________
Practice Name:________________________________ Date Last Seen:_____________________________
Therapist/Counselor: ________________________________ Phone #:___________________________
Practice Name:________________________________ Date Last Seen:_____________________________
Case Manager: ________________________________ Phone #:___________________________
Agency Name:________________________________ Date Last Seen:_____________________________
7. Additional Information/Remarks:
Signature, Credentials
Version 09.15.2014
Date