Contact | Virginia Therapy Services

Person Making Referral

Phone

Date and time of Referral

Month

Day

Year

Time

HoursMinutes

Date Of Contact

Email

Address

Name of Parent/Guardian/LAR : MHSB

Client Date Of Birth

Month

Day

Year

Preferred Method Of Contact

Name Of School (N/A If Not applicable)

Grade Completed

Insurance Type

Medicaid

Medicare

Private Insurance

Other

Primary Care Physician?

Insurance company Name

Medicare #

Medicaid #

Do you have a copy of Insurance

Yes

No

What services are you interested in receiving?

Does the individual have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community?

Yes

No

If yes, please explain using specific behaviors and settings in which these occurred including frequency and intensity of these behaviors, and avoiding vague words such as ‘aggressive’

Are you currently seeing, or have you seen a Psychiatrist/Psychologist in the past? (When, and Where) Have you had a Psychological Evaluation Completed? (If so When and where)

Any Psychotropic Medications? Please List Medications, Dosage and Frequency (Don’t forget to list who prescribed medication if at all possible)

Please indicate other medical/behavioral services and additional community supports/interventions received: Name of service/treatment Provider/Contact Information/address Frequency

Prior history of psychiatric hospitalization, residential crisis stabilization, placement in a psychiatric residential treatment facility, or Temporary Detention Order because of decompensation related to serious mental illness. (Add Name and Dates)

Please indicate other medical/behavioral services and additional community supports/interventions received. ( Please add Name and Provider Contact and Frequency)

Does individual exhibit such inappropriate behavior that repeated interventions (documented) by the mental health, social services or judicial system are or have been necessary resulting in being at risk for out of home placement?

Yes

No

If yes, explain the interventions being required by the community systems

Does the individual have a history of Legal Charges? Yes or No. Court ordered Treatment, On Probation? Name of Probation Officer and Name of Parole Officer. Name of Law Practice and Lawyer’s Name (if applicable)

Does the individual exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior to such a degree that they are at risk for out of home placement? (Explain)

Is the primary diagnosis schizophrenia/other psychotic disorder, Major Depressive Disorder-- Recurrent, or Bipolar I or II? Yes, No or Not Applicable

If the primary diagnosis is not one of the above has a physician documented any other mental health disorder within the last year resulting in all of the following?

Does the individual have a personality disorder, cognitive impairment, or intellectual disability? Yes or No. If yes, describe whether Mild, Moderate, Severe and how the individual is expected to actively participate in and benefit from services

Does individual require individualized training in acquiring basic living skills such as symptom management; adherence to psychiatric and medication treatment plans; development and appropriate use of social skills and personal support system;

If yes, please describe current symptoms and behaviors or other pertinent information which provides substantiation for the need for MHSS. (Identify the frequency, intensity and duration of each behavior and avoid using vague words such as ‘aggressive’)

Has the individual had a prescription for anti-psychotic, mood stabilizing, or anti-depressant medications within the 12 months prior to the assessment date? Yes Or No

a. If no, does the physician or other practitioner who is authorized by his license to prescribe medications indicate that anti-psychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual? Yes or No

If yes to 11a, describe how the individual will be able to actively participate in and benefit from services without the assistance of medication

Does the individual demonstrate a clinical necessity for this service arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities? Yes or No

Does the individual have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization* or out-of-home placement* because of conflicts with family or community? Yes or No

If yes, explain using specific behaviors and incidents that have occurred in the last 30 days, including the settings where these behaviors occur, the frequency, intensity, and duration of these behaviors, and avoid using vague words such as ‘aggressive”

Does the individual exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary? Yes No a. If yes, document the mental health, social services, or judicial

Does the individual require year-round treatment to sustain behavioral or emotional gains? Yes No a. If yes, describe how the individual would regress without year-round treatment:

As compared with same age peers, does the individual display any of the following? a. Deficits in social skills or peer relations or in dealing with authority? b. Hyperactivity? c. Poor impulse control? d. Signs of extreme depression?

If yes to any of the above, explain how these behaviors are more significant than those of same age peers using specific behaviors and incidents that have occurred in the last 30 days, including the settings where these behaviors occur

Please add:the frequency, intensity, and duration of these behaviors, and avoid using vague words such as ‘aggressive.’ If the individual displays aggressive type behaviors, please clearly define what this means

Additional Information ( Current and past Diagnosis Any Past Trauma? Resources and Strengths: Document individual’s strengths, preferences, extracurricular/community/social activities and people the individual identifies as supports.)

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