Home | Mental Health Skill Building Referral Form Mental Health Skill BuildingReferral Form Name(Required) First Last Date of Birth(Required) Month Day Year AgeGender Male Female Identifies asPhone Number(Required)Email(Required) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Individual Primary Language English Spanish Other Individual Primary Insurance Sentara Community Plans United Healthcare MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2a.)(Required) Schizophrenia or other Psychotic Disorder Major Depressive Disorder Bipolar I or Bipolar II MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2b.)(Required) Requires training in functional skills and appropriate behavior related to health and safety Requires training in activities of daily living; and use of community resources Requires assistance with medication management and/or adhering to a prescribed regimen of medication Assistance with monitoring health, nutrition and physical condition Requires training in acquiring basic living skills such as symptom management Requires training in adherence to psychiatric and medication treatment plans Requires training with developing and the appropriate use of social skills and personal support system Requires assistance with personal hygiene, food preparation and/or management MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2c.)(Required) Psychiatric Hospitalization Community Stabilization, 23-Hour Crisis Stabilization, or Residential Crisis Stabilization Unit Services Intensive Community Treatment (ICT) Program of Assertive Community Treatment (PACT) Psychiatric Residential Treatment Facility (RTC Level C) Temporary Detention Order (TDO) Evaluation as result of decompensation due to serious mental illness MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (2d.)(Required) Anti-Psychotic Psychiatric Medication Mood Stabilizing Psychiatric Medication Anti-Depressant Psychiatric Medication Psychiatric Medication is contraindicating MENTAL HEALTH SKILL-BUILDING SERVICES Eligibility Criteria (3. – ONLY If Referral is 20 years old or younger)(Required) In an independent living situation Actively transitioning into an independent living situation Not living with parent(s)/guardian(s) or in supervised setting Is providing his/her own financial support Please provide a brief description of the behaviors being exhibited by the individual being referred (reason for service request)(Required)Please provide a brief description of the challenging behaviors that have been observed.Name(Required) First Last Phone NumberEmail
