"Mental Health and Substance Abuse Outpatient Referral Form" - Delaware

Mental Health and Substance Abuse Outpatient Referral Form is a legal document that was released by the Delaware Department of Services for Children, Youth and their Families - a government authority operating within Delaware.

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Required Referral Information
Child’s demographic Information
Address
Race/Ethnicity
DOB
Guardian’s Information
Address
Phone Number
Guardianship paperwork
(if applicable)
Insurance Information
Medicaid
Proof of exhausted benefits (if applicable)
Treatment Information
Current diagnosis
Treatment questions
Signatures
Page 2 signed by legal guardian
Page 2 signed by child if 14 and older seeking substance abuse treatment
Releases
Mental health release completed:
Specifies who (agency/individual) information is to be released to
Signed by child’s legal guardian
Appropriate boxes are checked
Drug/Alcohol release
completed:
(when seeking substance abuse treatment)
Signed by legal guardian (only if child is under 14)
Signed by child if 14 and older
Appropriate boxes are checked
Child/Family History Chart (EPSDT)
Chart is filled out correctly and completely
**Please note, DPBHS Intake will be using this same form to determine if the
referral can be processed. If any of the above information is missing, the case will
not be opened for funding until the information is received.
Required Referral Information
Child’s demographic Information
Address
Race/Ethnicity
DOB
Guardian’s Information
Address
Phone Number
Guardianship paperwork
(if applicable)
Insurance Information
Medicaid
Proof of exhausted benefits (if applicable)
Treatment Information
Current diagnosis
Treatment questions
Signatures
Page 2 signed by legal guardian
Page 2 signed by child if 14 and older seeking substance abuse treatment
Releases
Mental health release completed:
Specifies who (agency/individual) information is to be released to
Signed by child’s legal guardian
Appropriate boxes are checked
Drug/Alcohol release
completed:
(when seeking substance abuse treatment)
Signed by legal guardian (only if child is under 14)
Signed by child if 14 and older
Appropriate boxes are checked
Child/Family History Chart (EPSDT)
Chart is filled out correctly and completely
**Please note, DPBHS Intake will be using this same form to determine if the
referral can be processed. If any of the above information is missing, the case will
not be opened for funding until the information is received.
MENTAL HEALTH AND SUBSTANCE ABUSE OUTPATIENT REFERRAL
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
1825 Faulkland Road Wilmington, DE 19805 (302) 633-2571 or (302) 633-2591
Please fill out this form completely and call if you need assistance.
Fax this form to (302) 622-4475
Date:
Child Name:
DOB:
Gender:
M
F
Race:
Ethnicity:
Child’s Current Address:
City/Town:
County:
State:
Zip:
Education: :
Regular Education
School:
Grade:
Special Education
Admit Date:____________
# of Attended Sessions: _____________
Parent/Guardian Name:___________________________________________
Address:___________________________________
City: _______________State: ____ Zip______
Phone: (H)______________________ (W)_____________________________
**If this is not the parent you must supply guardianship papers**
Insurance Information
Active Medicaid:
(Delaware Physicians Care, United Health Care, Diamond State Partners)?
Y
N
If yes, Medicaid # _______________________________
If no, has the application been submitted?
Y
N
Have sessions been exhausted?
Y
N
If the Benefits have been exhausted please provide proof (ie EOB, denial, etc.)
Clinical Eligibility
Client’s diagnosis (DSM IV including codes):
What is the client being treated for?
What are the treatment goals?
What has been improved upon?
What still needs to be addressed?
I understand that I am applying for DPBHS outpatient services. I attest that the information
listed above is correct to the best of my knowledge. I consent to the sharing of information
between DPBHS and the treatment provider for funding authorization, treatment planning, and
monitoring.
_________________________________________________
_____________
Signature Parent(s)/Legal Guardian/Custodian (circle one)
Date
CONSENT FOR RELEASE OF CONFIDENTIAL
SUBSTANCE ABUSE INFORMATION
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
I, ____________________________________________________________________, authorize
(Print name of youth)
Please check appropriate box:
Division of Family Services (DFS)
Department of Education (DOE)
Division of Youth Rehabilitation (YRS)
Multi Disciplinary Team (MDT)
Parent / Guardian
Deputy Attorney General’s Office (DAG)
Family Court
Public Defender (PD) / Private Attorney (PA)
Superior Court
Other (Please specify): _____________________________
To disclose
To receive from the Division of Prevention and Behavioral Health Services the
following information:
All information pertinent to substance abuse, including verbal communication, treatment progress
and assessment, drug screen reports, and discharge summary.
The purpose of the disclosure authorized herein is to: Assist in completion of Prevention and Behavioral
Health Services evaluation(s), treatment recommendations, and / or placement.
I understand that my records are protected under the federal regulations governing confidentiality of
Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written
consent, unless otherwise provided for in the regulations. I have the right to receive a copy of this form
after completing it. I also understand that I may revoke this consent at any time except to the extent that
action has been taken in reliance on it, and that in any event, this consent expires automatically as
follows:
THIS AUTHORIZATION WILL EXPIRE TWELVE (12) MONTHS FROM DATE OF
SIGNATURE
__________________________
______________________________
__________
Signature of Youth
Print Name of Youth
Date
(mandatory for children 14 years old and older)
__________________________
_________________________________
__________
Signature of Parent or Guardian
Print Name of Parent or Guardian
Date
(mandatory if client under 14 years old)
PROHIBITION ON REDISCLOSURE OF INFORMATION CONCERNING CLIENT IN
ALCOHOL OR DRUG ABUSE TREATMENT
This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment,
made to you with consent of such a client. This information has been disclosed to you from records
protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making
further disclosure of this information unless further disclosure is expressly permitted by the written consent
of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for
the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict
any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
CONSENT FOR RELEASE OF CONFIDENTIAL
MENTAL HEALTH INFORMATION
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
Client Name:
DOB:
I, (Parent/Guardian/Custodian/DFS)
hereby authorize the Division of Prevention and Behavioral
Health Services (DPBHS) to Release Verbal/Written Information to and to receive verbal and written information from:
Agency name or school:
Name of contact person at agency/school (if known):
Verbal and written information to be released by DPBHS: (Check all items that apply.)
Admission / Discharge Summaries (DPBHS services for past 2 years)
Service Admission Form (includes Demographics, CSM Service Plan, DPBHS Treatment History, Medication History, Risk Factors)
DPBHS Psychosocial Evaluation
DPBHS Psychological Evaluation
DPBHS Psychiatric Evaluation
Educational Records
Treatment Progress/Summary
Most recent physical exam (not to include pregnancy, STD, HIV information)
Other: ___________________________________________________________________
The purpose of this information disclosure by DPBHS is to: (Check all items that apply.)
Make a referral/provide treatment by the clinical treatment organization or person listed above
Assist in the completion of PBHS Evaluation(s)
Provide clinical information to organization or person named above
Verbal and written information to be released to DPBHS: (Check all items that apply.)
Initial Evaluation
Comprehensive Treatment Plan
Discharge Summary
Treatment Progress Summary
Physical Examination
Speech and Language Evaluation
Neurological Evaluation
Medication History
Psychiatric Evaluation
Most recent educational records including educational testing and school psychological, IEP/IPRD documents, school
attendance and behavioral/disciplinary records
Other _______________________________________________________
The purpose of this information disclosure by the agency/school named above is to: (Check all items that apply.)
Enable PBHS to Plan, Monitor, Authorize Payment, Coordinate Care with Treatment Provider
Enable PBHS to use the educational material in planning treatment
Enable PBHS to collaborate with the school in planning and providing services
Assist in the completion of PBHS Evaluation(s)
I understand that this form can not be used to release information about drug and alcohol treatment, pregnancy, HIV status, and sexually
transmitted diseases.
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in
writing and present it to the Director of Quality Improvement in the Division of Prevention of Behavioral Health Services. I understand that the
revocation will not apply to information that has already been released in response to this authorization.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need
to sign this release in order to be assured treatment. I understand that I may inspect or copy the information used or disclosed as provided in 45
C.F.R. 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and that the
information may not be protected by federal confidentiality rules. If I have any questions about the disclosure of my health information, I can
contact the Director of Quality Improvement, Division of Prevention and Behavioral Health Services.
This Release of Information demonstrates compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 C.F.R. pts. 160 and 164, and all federal regulations
and interpretive guidelines promulgated there under. Once the requested Personal Health Information (PHI) is disclosed, the recipient may re-
disclose it, therefore the privacy regulations may no longer protect it.
This authorization is valid for one year from the signature date unless revoked.
_______________________________________
Parent, Guardian, Custodian, DFS Signature (Circle one)
Print Name/Date
___________________________________________
_______________________________________
DSCYF Representative Signature
Print Name/Date