Mobile Crisis Referral Form

MEMBER INFORMATION
Name

Member First NameMember Last Name
Medicaid #
Member Date of Birth

MonthDayYear
Date
Member Plan ID #
Gender
Address

Member Address

Street Address Line 2

City, State, ZIPState / Province

Postal / Zip Code
Member Phone #
Parent/Guardian
Parent/Guardian Name
REASON FOR REFERRAL
Individuals must meet all of the following criteria:
1. The individual must be experiencing an active behavioral health crisis; and
2. Urgent intervention is necessary to stabilize or prevent escalation of the individual’s behavioral health crisis; and
3. The individual or collateral contact reports at least one of the following:
  1. suicidal/assaultive/destructive ideas, threats, plans or actions; or
  2. an acute or increasing loss of control over thoughts, behavior and/or affect that could result in harm to self or others; or
  3. functional impairment or escalation in mood/thought/behavior that is disruptive to the home, school, or the community or impacting the individual’s ability to function in these settings; or
4. the symptoms are escalating to the extent that a higher level of care will likely be required without intervention; and
5. Without urgent intervention, the individual will likely decompensate which will further interfere with their ability to function in at least one of the following life domains: family, living situation, school, social, work, or community.
Referring Organization Name
Printed Name
Title
Credentials(if applicable):
Referring Contact Phone Number
Please enter a valid phone number.
Referring Contact Email Address
example@example.com
Date:

MonthDayYear
Date
Mobile Crisis Referral Form Template 09.01.2022
Should be Empty:

MEMBER INFORMATION

Parent/Guardian