Healthy Homes Referral
WWW.HEALTHYMINDSLV.COM
Healthy Homes Referral This is a supplement to the Healthy Minds referral form Name: ________________________________ DOB: _________________ Date: ___________________ Healthy Homes is a program designed to provide rehabilitative services to Healthy Minds clients within the home environment. Healthy Homes works in conjunction with therapeutic services already being received by the client. Healthy Homes encompasses the needs of the identified client and expands to the family system. As each client is referred, Healthy Homes reserves the right to assess the compatibility of services provided to those that are recommended for the family being referred. Healthy Minds utilizes weekly goals to determine progress and therefore will refer the client back to the therapist should it be determined by the treatment team that rehabilitative services are not compatible.
☐ Male ☐ Female ☐ N/A
Gender preference for Support Specialist
Selection criteria: ☐ Yes ☐ No Current Healthy Minds client If no, where is the client receiving services if any? (Please provide the name and phone number) Name: _________________________________ Phone: ________________________________ ☐ Yes ☐ No Client is between the ages of 5–17; Date of birth: ___/___/______ ☐ Yes ☐ No Currently enrolled in FFS Medicaid ☐ Yes ☐ No Client AND family are currently without a PSR/BST worker ☐ Yes ☐ No The client and the family could benefit from rehabilitative services ☐ Yes ☐ No Client has an Axis I or Axis II diagnosis of Adjustment Disorder, Mood & Depressive Disorder, Attention Deficit and Disruptive Behavior Disorder, Conduct Disorder, and/or Oppositional Defiant Disorder (Please indicate any other diagnosis: ___________________________________________________________) Internal: Please only complete the section below if you are a referring Healthy Minds clinician ☐ Yes ☐ No Has completed four or more individual and/or family sessions ☐ Yes ☐ No Client is recommended for a Level III or higher on the most recent CASII *A new CASII is required at the time of a HH referral. Date of completed CASII: ________ ☐ Yes ☐ No HMA updated within 90 days of HH Referral ☐ Yes ☐ No Treatment Plan updated and uploaded
RETURN TO [email protected] (702) 455-4629 Rev. 3/13/17 Pg. 1 of 2
WWW.HEALTHYMINDSLV.COM
Healthy Homes Referral contd. Please list names and ages of all other individuals living in the home (attach additional). Name:
Age:
Healthy Minds Client? ☐ Yes ☐ Yes ☐ Yes ☐ Yes ☐ Yes
☐ No ☐ No ☐ No ☐ No ☐ No
☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
Please list other individuals that may be present during home visits: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Additional Notes: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
RETURN TO [email protected] (702) 455-4629 Rev. 3/13/17 Pg. 2 of 2
Healthy Homes Referral This is a supplement to the Healthy Minds referral form Name: ________________________________ DOB: _________________ Date: ___________________ Healthy Homes is a program designed to provide rehabilitative services to Healthy Minds clients within the home environment. Healthy Homes works in conjunction with therapeutic services already being received by the client. Healthy Homes encompasses the needs of the identified client and expands to the family system. As each client is referred, Healthy Homes reserves the right to assess the compatibility of services provided to those that are recommended for the family being referred. Healthy Minds utilizes weekly goals to determine progress and therefore will refer the client back to the therapist should it be determined by the treatment team that rehabilitative services are not compatible.
☐ Male ☐ Female ☐ N/A
Gender preference for Support Specialist
Selection criteria: ☐ Yes ☐ No Current Healthy Minds client If no, where is the client receiving services if any? (Please provide the name and phone number) Name: _________________________________ Phone: ________________________________ ☐ Yes ☐ No Client is between the ages of 5–17; Date of birth: ___/___/______ ☐ Yes ☐ No Currently enrolled in FFS Medicaid ☐ Yes ☐ No Client AND family are currently without a PSR/BST worker ☐ Yes ☐ No The client and the family could benefit from rehabilitative services ☐ Yes ☐ No Client has an Axis I or Axis II diagnosis of Adjustment Disorder, Mood & Depressive Disorder, Attention Deficit and Disruptive Behavior Disorder, Conduct Disorder, and/or Oppositional Defiant Disorder (Please indicate any other diagnosis: ___________________________________________________________) Internal: Please only complete the section below if you are a referring Healthy Minds clinician ☐ Yes ☐ No Has completed four or more individual and/or family sessions ☐ Yes ☐ No Client is recommended for a Level III or higher on the most recent CASII *A new CASII is required at the time of a HH referral. Date of completed CASII: ________ ☐ Yes ☐ No HMA updated within 90 days of HH Referral ☐ Yes ☐ No Treatment Plan updated and uploaded
RETURN TO [email protected] (702) 455-4629 Rev. 3/13/17 Pg. 1 of 2
WWW.HEALTHYMINDSLV.COM
Healthy Homes Referral contd. Please list names and ages of all other individuals living in the home (attach additional). Name:
Age:
Healthy Minds Client? ☐ Yes ☐ Yes ☐ Yes ☐ Yes ☐ Yes
☐ No ☐ No ☐ No ☐ No ☐ No
☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
Please list other individuals that may be present during home visits: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Additional Notes: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
RETURN TO [email protected] (702) 455-4629 Rev. 3/13/17 Pg. 2 of 2
