ࡱ>  @bjbj 4!/  \\\\\ppp8TtpsNfp@ !!!!" 05&M(M(M(M(M(M(M$ORLM\8""88LM\\!!4-N>>>8R\!\!&M>8&M>>VrE@6F!pS}p8jE MCN0sNExGS8lGS6F6FGS\JF88>88888LMLMF:888sN8888GS888888888 ": County of San Diego HHSA Adult/Older Adult Behavioral Health Services ASSERTIVE COMMUNITY TREATMENT (ACT) FOR HOMELESS PERSONS WITH SEVERE MENTAL ILLNESS REFERRAL FORM *** Hover the pointer over the program title, right click the mouse and select Open Hyperlink for more information. *** REFERRAL TO ASSERTIVE COMMUNITY TREATMENT (ACT) PROGRAMS  FORMCHECKBOX  HYPERLINK "http://www.comresearch.org/serviceDetails.php?id=NDA="Community Research Foundation Adelante (South): (619) 934-5770; Fax: (619) 391-0091  FORMCHECKBOX   HYPERLINK "http://www.comresearch.org/serviceDetails.php?id=Mw==" Community Research Foundation Downtown IMPACT (Central): (619) 398-2156; Fax: (619) 398-2168  FORMCHECKBOX   HYPERLINK "http://www.comresearch.org/serviceDetails.php?id=NA==" Community Research Foundation IMPACT (Central/North Central): (619) 398-0355; Fax: (619) 398-0350  FORMCHECKBOX   HYPERLINK "http://www.comresearch.org/serviceDetails.php?id=MzI=" Community Research Foundation Senior IMPACT (Countywide): (619) 977-3716; Fax: (619) 481-3075  FORMCHECKBOX   HYPERLINK "https://www.mhsinc.org/listing/center-star-act-2/" Mental Health Systems (MHS) Center Star ACT (Countywide): (619) 521-1743; Fax: (619) 521-1896  FORMCHECKBOX  HYPERLINK "https://www.mhsinc.org/listing/city-star-act/"Mental Health Systems (MHS) City Star ACT (Central/North Central): (858) 609-8742; Fax: (858) 292-0322  FORMCHECKBOX  HYPERLINK "https://www.mhsinc.org/listing/north-coastal-act/"Mental Health Systems (MHS) North Coastal ACT (North): (760) 290-8170; Fax: (760) 439-0019  FORMCHECKBOX   HYPERLINK "https://www.mhsinc.org/listing/north-star-act-2/" Mental Health Systems (MHS) North Star ACT (North): (760) 432-9884; Fax: (760) 432-9953  FORMCHECKBOX   HYPERLINK "https://www.kickstartsd.org/catalyst-assertive-community-treatment/" Pathways Catalyst ACT (Countywide): (858) 300-0460; Fax: (858) 300-0461  REFERRAL TO ASSERTIVE COMMUNITY TREATMENT - SUBSTANCE ABUSE TREATMENT PROGRAMS (Dual Track Programs)  FORMCHECKBOX  HYPERLINK "https://www.mhsinc.org/listing/action-central/"Mental Health Systems (MHS) ACTION Central: (619) 287-8225; Fax: (619) 287-4146  FORMCHECKBOX  HYPERLINK "https://www.mhsinc.org/listing/action-east/"Mental Health Systems (MHS) ACTION East: (619) 383-6868; Fax: (619) 312-2661  REFERRING PARTY INFORMATION Date of Referral:  FORMTEXT      / FORMTEXT      / FORMTEXT       Name of Person Making Referral:  FORMTEXT       Email of Referring Party, if available*:  FORMTEXT       FORMTEXT  Referring Agency: Address:  FORMTEXT       Phone: ( FORMTEXT    )-  FORMTEXT      -  FORMTEXT       Fax: :(  FORMTEXT       )  FORMTEXT      - FORMTEXT       *If choosing to communicate via email, please ensure compliance to Article 14 and confidentiality requirements. Email may be used between providers and referring parties as long as no client information is included unless encryption is used. This referral form should never be sent via email unless encrypted.  IDENTIFYING INFORMATION OF PERSON BEING REFERRED Name: FORMTEXT       SS# (Last 4 ONLY):  FORMTEXT      DOB:  FORMTEXT      / FORMTEXT      / FORMTEXT       Age:  FORMTEXT       MIS#:  FORMTEXT       Aliases:  FORMTEXT      Gender: FORMTEXT       Language of Preference:  FORMTEXT       Ethnicity:  FORMTEXT       Address:  FORMTEXT       Phone: ( FORMTEXT      ) FORMTEXT      - FORMTEXT       Has he/she ever been Homeless?  FORMCHECKBOX YES  FORMCHECKBOX NO Period of Homelessness:  FORMTEXT       Is he/she connected to Whole Person Wellness ?  FORMCHECKBOX YES  FORMCHECKBOX NO Alternate Telephone Number or Other Supports:  FORMTEXT       Relation:  FORMTEXT       Phone: ( FORMTEXT      ) FORMTEXT      - FORMTEXT        CLINICAL INFORMATION Is Person Interested in Case Management?  FORMCHECKBOX YES  FORMCHECKBOX NO Provide Specific Reason(s) for Referral:  FORMTEXT       Current Problems, Barriers, Challenges, OR Problems When Person is Not Stable:  FORMTEXT       Mental Health Stage of Recovery:  FORMCHECKBOX Pre-Contemplation  FORMCHECKBOX Contemplation  FORMCHECKBOX Preparation  FORMCHECKBOX Action  FORMCHECKBOX Maintenance  FORMCHECKBOX Relapse History of Mental Health Treatment:  FORMTEXT       Number of Psych Hospitalizations in the past year:  FORMTEXT   Reasons: FORMTEXT       Does Person Have Problematic Use of Substances?  FORMCHECKBOX YES  FORMCHECKBOX NO Date of Last Use:  FORMTEXT      / FORMTEXT      / FORMTEXT       Substance(s) of Choice:  FORMTEXT       Substance Use Stage of Recovery:  FORMCHECKBOX Pre-Contemplation  FORMCHECKBOX Contemplation  FORMCHECKBOX Preparation  FORMCHECKBOX Action  FORMCHECKBOX Maintenance  FORMCHECKBOX Relapse History of Drug/Alcohol or Co-Occurring Treatment: ddd Risk for Harm or Dangerous Propensities (e.g., Suicide Attempts, SI, HI, Command AH, Hx of Violence, Threats, Risky Behavior):  FORMTEXT       Current Impairments in Daily Functioning:  FORMTEXT       Goals, Strengths, and Interests:  FORMTEXT      CULTURAL FACTORS RELATED TO MENTAL HEALTH:  FORMTEXT        DIAGNOSES  +5Fjk   # $ Ƽwkw_SDhV!hB*CJaJphhJSB*CJaJphhg:B*CJaJphh B*CJaJphhoB*CJaJphhV!hV!B*CJaJphhV!hFB*CJaJphhIhoCJ aJ hc|h;5hc|h4.5h4.5B*phhFho5B*phh,oh<5B*phh,oh;5B*ph h<5hXh<5 hh5Fk$ % ^ _ ` _ ` A B C D 9 : !"   $Ifgdh $IfgdgdcA$a$gdo$a$gd<$ % . / U ] ^ _ ` a o p q r s Ķ󧜊~vg~ZMZCZ~hS0JCJaJhhL0JCJaJhhh0JCJaJjvh696CJUaJh696CJaJjhhCJUaJ#jh KhhCJUaJh KhhCJaJjh KhhCJUaJh Kh;5>*CJaJhl(5>*CJaJh5>*CJaJh R5>*CJaJh Khl(5>*CJaJhh K5CJaJ % & 6 7 ^ _ ` a o p q r s  + , ; ? @ A B C Q R S T U 𞭑zr`#jh Kh[CJUaJh.gZCJaJhS0JCJaJhhh0JCJaJhhL0JCJaJjhhCJUaJjhhCJUaJ#jkh KhhCJUaJjh KhhCJUaJhhkCJ aJ h KhhCJaJhhCJaJhSCJaJ%U   B C D E S T U V W   ùݮn_ùݮjhhCJUaJ#jAh KhhCJUaJjh KhhCJUaJhhkCJ aJ h,ohS>*CJaJhSCJaJh KhhCJaJhS0JCJaJhhh0JCJaJhhL0JCJaJjhhCJUaJjLhhCJUaJhhCJaJ% 8 9 : ; I J K L M  !"#1wlaYhSCJaJh696hSCJaJh696hhCJaJh696hS0JCJaJh696hoc0JCJaJh696hh0JCJaJj"h696CJUaJh696CJaJjh696CJUaJ#jh KhhCJUaJjh KhhCJUaJhhkCJ aJ hhCJaJh KhhCJaJ12345nopq    ǿǣDŽ|ӄqi^L#jjh KhhCJUaJhhkCJ aJ hhCJaJh]hhCJaJhSCJaJhhCJaJhS0JCJaJhhoc0JCJaJhhh0JCJaJjhMCJUaJhMCJaJjhhCJUaJh KhhCJaJjh KhhCJUaJ#jh Kh[CJUaJ[\]^uwx GHIJacdsйݱrݩcjC hhCJUaJ#j h KhhCJUaJjh KhhCJUaJhhkCJ aJ h KhhCJaJhhCJaJhSCJaJh#r0JCJaJhhoc0JCJaJhhh0JCJaJjhhCJUaJjh\tHCJUaJh\tHCJaJ"st{|}~MNOdqrstȄuȸmbhh KCJaJhtCJaJj hhCJUaJ#j. h KhhCJUaJjh KhhCJUaJhhkCJ aJ h696CJaJhSCJaJhhCJaJh KhhCJaJjhhCJUaJhhh0JCJaJh#r0JCJaJhS0JCJaJ#cdeHPzqhhhhh $Ifgd K $IfgdN`skd $$Ifl*P+ t0P+644 lap yt?  $Ifgd $Ifgdh DLbcdeftuvwx·rj^VG^:hh6-0JCJaJj h2fCJUaJh2fCJaJjhU{MCJUaJh KCJaJ#j@ h KhN`CJUaJh KhN`CJaJjh KhN`CJUaJhh K5>*CJaJhc|5>*CJaJhN`5>*CJaJh Kh715>*CJaJhu-=5>*CJaJh KhN`5>*CJaJhh K5CJaJh h[CJaJ!"(23GHOPQ_`abcº§”zh`XIjh2fCJUaJh2fCJaJh KCJaJ#jh Kh? 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FORMCHECKBOX YES  FORMCHECKBOX NO Name of Conservator:  FORMTEXT       Phone: ( FORMTEXT      ) FORMTEXT      -  FORMTEXT       Has Person been Incarcerated or Had Legal Issues?  FORMCHECKBOX YES  FORMCHECKBOX NO If yes, please explain:  FORMTEXT       Person is on  FORMCHECKBOX Parole  FORMCHECKBOX Probation Parole/Probation Officer: FORMTEXT       Phone: ( FORMTEXT      ) FORMTEXT      - FORMTEXT       Other Pertinent Legal Information or Restrictions:  FORMTEXT        FINANCIAL / ppppppqqqqqqqqqrrrrrrrrrrrrrrr޾޾ޘ޾޾޾~sh\Nh7h#45>*CJaJhh5CJaJh h[CJaJhhCJaJhl(CJaJ#jS5h hl(CJUaJjhe^CJUaJ#j4h hl(CJUaJh#4CJaJh hl(CJaJ(jh hl(CJUaJmHnHujh hl(CJUaJ#jg4h hl(CJUaJrrr sssty dh$Ifgd $Ifgdqkd5$$Ifl*P+ t0P+644 lap yt rrrrrrs s ssLsNsbsdsfspsrsssssssssss䪟ٍ~sa~L~~s(jh hCJUaJmHnHu#jN7h hCJUaJh hCJaJjh hCJUaJ#j6h h#4CJUaJhhCJaJh#4CJaJ(jh h#4CJUaJmHnHu#jP6h h#4CJUaJh h#4CJaJjh h#4CJUaJh h#45CJaJsssssssssssssttt0t4t6tJt޾޳ޙtfZK@h hl(CJaJjh hl(CJUaJh7hl(5CJaJh7hl(5>*CJaJhh5>*CJaJh h[CJaJhh5CJaJh#4CJaJ#jZ8h hCJUaJh hCJaJh h#4CJaJ(jh hCJUaJmHnHujh hCJUaJ#j7h hCJUaJttt\t^t@uBu|| $Ifgd .7 $Ifgdqkd8$$Ifl*P+ t0P+644 lap yt JtLtNtXtZt\t^tttttttttttttttttuu uuޫލޫ~sa~U~~sC~U#j:h hCJUaJjhA4CJUaJ#jw:h hCJUaJh hCJaJjh hCJUaJjh CJUaJ#j9h hl(CJUaJh hl(CJaJhhCJaJhl(CJaJ(jh hl(CJUaJmHnHujh hl(CJUaJ#jg9h hl(CJUaJuuuu.u0u2uu@uBuDuFujuluuuuuuuuuuuvv,v𴩞sassOss#j=h hl(CJUaJ#j<h hl(CJUaJjh hl(CJUaJh .7hl(5>*CJaJhh5>*CJaJh h[CJaJhh .7CJaJhCJaJjhA4CJUaJ#j;h hCJUaJh hCJaJh hl(CJaJjh hCJUaJBuDuFujuluvwTyyyyyyy dh$Ifgd $Ifgdqkd <$$Ifl*P+ t0P+644 lap yt ,v.v0v:vh hCJUaJ(jh hCJUaJmHnHu#j>h hCJUaJh hCJaJjh hCJUaJh hl(CJaJ(jh hl(CJUaJmHnHujh hl(CJUaJ#j|=h hl(CJUaJPwRwTwbwdwwwwwwwwwwwwxxx x0x2xNxPxRxdxnxxxxxxӯޣӑwe#jAh hl(CJUaJh2CJaJ#jAh hl(CJUaJ#j Ah hl(CJUaJjhe^CJUaJ#j@h hl(CJUaJ#j @h hl(CJUaJh hl(CJaJjh hl(CJUaJ#j?h hl(CJUaJxxxxxxxxyyyyyyy(y*y,y.yByDyFyPyRyyyyyyyyy··~·lZRhl(CJaJ#jDh hl(CJUaJ#jCh hCJUaJ#jCh hCJUaJ(jh hCJUaJmHnHu#j~Bh hCJUaJh hCJaJjh hCJUaJh hl(CJaJjh hl(CJUaJ(jh hl(CJUaJmHnHuyyyyz,.hjДҔ "$46RTVfhôâôÐô~ôlôZô#jFh hl(CJUaJ#j}Fh hl(CJUaJ#j Fh hl(CJUaJ#jEh hl(CJUaJ#jEh hl(CJUaJjh hl(CJUaJh hl(CJaJUh .7hl(5>*CJaJhh5CJaJh h[CJaJhho=CJaJ#yyy,.zPRyyyypp $Ifgdt dh$Ifgd $IfgdqkdD$$Ifl*P+ t0P+644 lap yt INSURANCE INFORMATION Current Source of Income:  FORMCHECKBOX SSI  FORMCHECKBOX SSDI  FORMCHECKBOX SDI  FORMCHECKBOX WORK  FORMCHECKBOX NONE  FORMCHECKBOX Other: FORMTEXT       Payee:  FORMTEXT       Phone: ( FORMTEXT      ) FORMTEXT      - FORMTEXT       Current Insurance Status:  FORMCHECKBOX Medi-Cal  FORMCHECKBOX Medicare  FORMCHECKBOX VA  FORMCHECKBOX Indigent Medi-Cal #:  FORMTEXT       Medicare #:  FORMTEXT       Private/Other Insurance Information:  FORMTEXT       Policy #:  FORMTEXT       Phone: ( FORMTEXT      ) FORMTEXT      - FORMTEXT        Signature of Person Completing Referral: ___________________________________________ Date:  FORMTEXT      / FORMTEXT      / FORMTEXT        This electronic form can also be found in the HYPERLINK "https://www.sandiegocounty.gov/content/sdc/hhsa/programs/bhs/technical_resource_library.html"Technical Resource Library (TRL) and/or HYPERLINK "http://sandiego.networkofcare.org/mh/services/content.aspx?id=6573"Network of Care.     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