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About
Referral Information
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Residential
Crisis Response & Respite
Outpatient
Education Advocacy & Support
Jobs
Blog
Employee Information
Mental Health Respite Referral
Mental Health Respite Referral Form
Section 1: Referring Agency Information
Referring Individuals Information
(Required)
First
Last
Agency
(Required)
Phone
(Required)
Email
(Required)
Date of Referral
MM slash DD slash YYYY
Date of Intake at Referring Agency
MM slash DD slash YYYY
Section 2: Participant Information
Client Information
(Required)
First
Last
Gender
(Required)
Male
Female
Non-binary
My gender isn't listed
Prefer Not to Answer
Preferred Pronouns:
Social Security Number
(Required)
Birthday
(Required)
MM slash DD slash YYYY
Employment Status
Active Military Duty
Disabled
Employed Full Time
Employed Part Time
Not Employed
Retired
Student
Unkown
Region
One
Two
Three
Four
Five
Six
Phone
Preferred Language
Race
American Indian or Alaska Native
Asian or Native Hawaiian or Pacific-Islander
Black or African American
Middle Eastern or North African
White
Unknown
Decline to answer
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Decline to answer
Marital Status:
Highest Level of Education:
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Section 3: Legal & Guardianship Status (Check all that apply)
Contact Type
(Required)
Attach ALL Guardianship/Payee/Conservator Paperwork to Referral
Guardian
Payee
Conservator
Self
Name
First
Last
Relationship to Client
Phone
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Emergency Contact:
Name
First
Last
Phone
Insurance/Benefit Information
Insurance/Payment
(Required)
Medicaid
Medicare
Dual Complete Plan
Private Pay
VA Benefits
Region Funded
Medicaid Type:
Nebraska Total Care
United
Molina
Region Responsible for Funding:
One
Two
Three
Four
Five
Six
Subscriber ID
(Required)
Attach all current insurance card copies and benefit award letters regarding income sources
BIN Number
Group Number
SSI/SSDI Benefits received:
Section 4: Reason for Referral:
Describe the current status or circumstances leading to referral:
Additional admission information
(Required)
Voluntary Admission
Court-involvment
Mental Health Board commitment (Note - cannot have a commitment to VCRC programming)
Explain:
What is the intended outcome of the respite stay?
(Required)
Return home
Attend mental health or substance use treatment care
Return to unsheltered/homeless status
Community reintegration support
Treatment facility:
(Required)
Community support agency:
(Required)
Section 5: Clinical Summary
SPMI Diagnosis Required:
(Required)
Schizophrenia
Schizoaffective Disorder
Major Depressive Disorder
Bipolar Disorder
Obsessive Compulsive Disorder
Other Diagnoses:
Add
Remove
Mental Status Overview
(Required)
Oriented
Disoriented
Suicidal Ideation
Homicidal Ideation
Psychosis
Anxiety
Details:
Current risk level
(Required)
Mild
Moderate
Severe
Describe:
Recent Psychiatric Hospitalizations (last 90 days)
Add
Remove
Section 6: Mental Health Supports and Medical Information
Please attach any current MARS below
Check all that apply:
(Required)
Drug Allergies
Food Allergies
Environmental Allergies
None
Allergies:
Add
Remove
Check all that apply:
Mobility Concerns
Physical Injuries
Memory Concerns
Scheduled Injection
Explain:
Frequency & Date of last injection
Current Providers:
(Required)
Add
Remove
Upcoming/Scheduled Appointments
Provide any current lab work within six months of referral date
Add
Remove
Formal supports in place:
Agencies currently working with the individual and contact information
Add
Remove
Section 7: Eligibility Checklist (per NAC)
All criteria must be met/boxes be checked
(Required)
Individual is experiencing a behavioral health crisis but does not require inpatient hospitalization
Symptoms can be managed in a voluntary, non-secure, short-term setting
Individual is not actively suicidal/homicidal or medically unstable
The individual consents to the admission and understands the voluntary nature
Section 8: Attachments required
Latest psychiatric evaluation
(Required)
(Proof of diagnosis)
Max. file size: 256 MB.
Crisis plan/safety plan and discharge plan
(Required)
(Proof of diagnosis)
Max. file size: 256 MB.
Release of Information to referring agency
(Required)
Max. file size: 256 MB.
Releases to any formal supports
Max. file size: 256 MB.
Medication list
Max. file size: 256 MB.
Release of information to pharmacy
Max. file size: 256 MB.
Guardianship/Payee Information
Max. file size: 256 MB.
MHB Commitment Paperwork
Max. file size: 256 MB.
Section 9: Understanding and Agreement:
Understanding and agreement.
(Required)
This referral is for placement in the Mental Health Respite Program, which is a voluntary service. Please review and confirm the following:
-The respite program is not a locked facility
-Individuals may leave the facility unsupervised between the hours of 8:00 am and 8:00 pm daily
-Participation in this program is completely voluntary. Individuals may request to discharge or check out of programming at any time
-The respite program is not a substitute for inpatient psychiatric hospitalization
-Stays in Mental Health Respite programs can affect eligibility for authorization of residential levels of care
-If higher levels of care are needed for safety, the referral source and formal supports will be contacted to assist with coordination
I understand and agree to the conditions of respite programming.
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