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Page |1 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] [Type text] [Type text] [Type text] Outreach Services Request and Referral Form Page 2 of 5 Outreach Services Request and Referral Form Page 3 of 5 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 Page 4 of 5 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 ______________________ Outreach Services Request and Referral Form Page 5 of 5 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