Referral Form - Targeted Case Management

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Referring Agency

Agency Name

Employee Name

Employee Email

Employee Phone

Client Information

Client Name

Address
Phone
DOB
SSN
Date
Phone
Does the child / adult have a medical card?
YesNo
MAID #

Please Select One of the Following Diagnostic Codes (DX) Schizophrenia Spectrum and Other Psychotic Disorders / Delusional Disorder / 297.1Schizophreniform Disorder / 295.40Schizophrenia / 295.90SchizoAffective Disorder / 295.70Other Specified Schizophrenia Spectrum and Other Psychotic Disorder / 298.8Unspecified Schizophrenia Spectrum and Other Psychotic Disorder / 298.9Bipolar and Related Disorders / Bipolar I Disorder / 296.41, 296.42, 296.43, 296.51, 296.52, 296.53, 296.44, 296.45, 296.46, 296.40, 296.54, 296.55, 296.50Bipolar II Disorder / 296.89Cyclothymic Disorder / 301.13Other Specified Bipolar and Related Disorder / 296.89Unspecified Bipolar and Related Disorder / 296.80Depressive Disorders / Major Depressive Disorder / 296.21, 296.31, 296.22, 296.32, 296.23, 296.33, 296.24, 296.34, 296.25, 296.35, 296.20, 296.30Persistent Depressive Disorder (Dysthymia) / 300.4Other Specified Depressive Disorder / 311Unspecified Depressive Disorder / 311Trauma and Stressor Related Disorders / Posttraumatic Stress Disorder / 309.81Alcohol-Related Disorders / Alcohol Use Disorder-Moderate / 303.90Alcohol Use Disorder-Severe / 303.90Cannabis-Related Disorders / Cannabis Use Disorder-Moderate / 304.30Cannabis Use Disorder-Severe / 304.30Hallucinogen-Related Disorders / Phencyclidine Use Disorder-Moderate / 304.60Phencyclidine Use Disorder-Severe / 304.60Other Phencyclidine Use Disorder-Moderate / 304.50Other Phencyclidine Use Disorder-Severe / 304.50Inhalant-Related Disorders / Inhalant Use Disorder-Moderate / 304.60Inhalant Use Disorder-Severe / 304.60Opioid-Related Disorders / Opioid Use Disorder-Moderate / 304.00Opioid Use Disorder-Severe / 304.00Sedative-,Hypnotic-,or Anxiolytic-Related Disorders / Sedative, Hypnotic, or Anxiolytic Use Disorder-Moderate / 304.10Sedative, Hypnotic, or Anxiolytic Use Disorder-Severe / 304.10Stimulant-Related Disorders / Amphetamine-type substance-Moderate / 304.40Cocaine-Moderate / 304.20Other or unspecified stimulant-Moderate / 304.40Amphetamine-type substance-Severe / 304.40Cocaine-Severe / 304.20Other or unspecified stimulant-Severe / 304.40Other (or Unknown) Substance-Related Disorders / Other (or Unknown) Substance-Related Use Disorder-Moderate / 304.90Other (or Unknown) Substance-Related Use Disorder-Severe / 304.90

Reasons for Referral
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