ACT Program | Referral Form (DETAILED)

Pre-Screening and Eligibility Referral Form ACT Program - Merakey Virginia -

Submission of a completed Pre-Screening and Eligibility Referral Form (this form) and all documents identified below are required for referral to the Merakey Virginia ACT programs. The absence of any required item interrupts the evaluation process and could delay screening for admission.
Date

MonthDayYear
Check one:
Referring Provider Information
Provider Name
Contact Person
Provider Email
example@example.com
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consumer Information
Consumer Full Name

First NameLast Name
Consumer Date of Birth

MonthDayYear
Consumer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Consumer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicaid Number
Social Security Number
A. Please Complete the Following Information Based on Clinical Records, Treatment, and when appropriate, Feedback From The Individual and Their Natural Supports:
Primary Diagnosis/Additional Diagnoses (including medical dx):
History of Hospitalizations (dates, location, reason for admission):
Previous Known Admission to Merakey ACT Programs:
Presenting Problem:
Critical and Urgent Needs:
Unsafe Substance Use:
Eligibility Criteria: Criteria B and C must be met.
B. CHECK ALL THAT APPLY. Must meet all of the following:

The individual must have a primary diagnosis of a severe and persistent mental illness (SPMI) which includes the following: 1) Psychotic Disorder such as Schizophrenia or Schizo-affective Disorder 2) Major Mood Disorder such as Major Depressive Disorder or Bipolar Disorder OR
C. CHECK ALL THAT APPLY. Must meet three or more of the following:
At least one of the following (check any that apply):
Potential Exclusion Criteria: Identification of one or more of the following potential exclusionary criteria does not necessarily rule out eligibility for admission into ACT services but does warrant further assessment to ensure that the ACT program is the most appropriate level of care and is beneficial to the individual.
D. CHECK ALL THAT APPLY. If any criteria are checked, additional assessment may be required. The individual has a primary diagnosis of at least one of the following (check any that apply):
E. Clinical Packet Attachments: The following items are required to be submitted with this form to complete referral. NOTE: The absence of any of the following items interrupts the evaluation process and could delay or suspend the admission process. REQUIRED

Other (If unable to provide above documentation, please explain why)
PREFERRED, BUT NOT REQUIRED
DISCLAIMER: Completion of this screening does not constitute a guarantee of admission into ACT. All referral packets are subject to the comprehensive review of the ACT Team before decision on admission can be made.
Signature
Date

MonthDayYear
Completed Referral Packet (including Pre-Screening and Eligibility Referral Form and Attached Clinical Packet) should be faxed or sent directly to the Merakey ACT Provider for review.
ITEMS IN THE AREA BELOW ARE TO BE FILLED OUT BY
ACT STAFF REVIEWING REFERRAL UPON COMPLETION
OF REFERRAL SCREENING
F. To Be Completed and Checked-off by ACT Staff Responsible for Reviewing Screening:
Note status of insurance:
G. Disposition:
Comments About Disposition Decision Including Plan:
Signature
Date

MonthDayYear
By signing, staff are confirming review of full referral.
Should be Empty:

Pre-Screening and Eligibility Referral Form ACT Program - Merakey Virginia -