TARGETED CASE MANAGEMENT CONTACT / REFERRAL FORM

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To find a provider accepting referrals in your area, please contact your local Base Service Unit, CCBH Member services at: 1-866-738-9849 or visit: https://members.ccbh.com/find-provider

Referral Date *

County *

Referrer Information

Referral Source *

Referral Contact Name *

Relationship to Person being Referred *

Referral Phone Number

Referral Email Address

Individual Seeking Service

Name of Individual Seeking Service *

Social Security Number *

Age

Date of Birth *

Individual's Address

Parent or Guardian Name

City and State

Zip Code

Homeless Status

At least one phone or email contact method is required:

Phone (Home)

Phone (Cell)

Phone (Work)

Phone (Other)

Individual's Email Address

Does the individual currently have probation/parole officer or criminal justice involvement? *

If Yes, please provide more information.

Select the Domains of Wellness that you wish to address? (check all that apply) *

Physical Intellectual Emotional Social Spiritual Vocational Financial Environmental

Does the Individual Require Special Accommodations?

Does the Individual have Special Preferences?

Gender Preference of Case Manager

Location Preference for Services

Language Preference

Additional Information

Attachments

Note: Maximum file size allowed by the server is 10 MB per attachment. PDF, JPG, PNG, or TIFF only — executable files (EXE, PHP, scripts) are blocked.

Please attach evidence of diagnosis (if available). Examples includes most recent psychiatric/psychological evaluation, treatment plan signed by Practitioner of the Healing Arts, Health Physical listing primary diagnosis)

Attachment 1 (optional)

PDF, JPG, PNG, or TIFF up to 10MB

Attachment 2 (optional)

PDF, JPG, PNG, or TIFF up to 10MB

Attachment 3 (optional)

PDF, JPG, PNG, or TIFF up to 10MB

Attachment 4 (optional)

PDF, JPG, PNG, or TIFF up to 10MB

Attachment 5 (optional)

PDF, JPG, PNG, or TIFF up to 10MB

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Please correct the following

CHILDREN'S TARGETED CASE MANAGEMENT (must meet one criteria in A and B)

DIAGNOSIS:
Diagnosis within most recent version of DSM or ICD (excludes Developmental Disabilities, psychoactive substance abuse, organic brain syndrome, or a V- Code.)
TREATMENT HISTORY (must meet one of the following)
- Six or more days of psychiatric inpatient treatment in the past twelve months.
- Without Targeted Case Management services would result in placement in a community inpatient unit, state mental hospital, or other out-of-home placement, including foster homes or juvenile court placements.
- Currently receiving or in need of mental health services and receiving or in need of services from two or more human service agencies or public systems such as Education, Child Welfare, Juvenile Justice, etc.
TRANSITION
A child or adolescent who currently receives intensive case management or resource coordination services.
WAIVER (if this option is selected acceptance is subject to review and approval)
A child or adolescent who needs to receive Targeted Case Management services, but does not meet the requirements identified above, may be eligible for Targeted Case Management upon review and recommendation by the County Administrator or his/her designee, or the Behavioral Health Managed Care Organization, as applicable.

ADULT'S TARGETED CASE MANAGEMENT (must meet one criteria in A and B)

DIAGNOSIS:
Diagnosis within most recent version of DSM or ICD (excludes Developmental Disabilities, psychoactive substance abuse, organic brain syndrome, or a V- Code.)
TREATMENT HISTORY (must meet one of the following)
- Six or more days of psychiatric inpatient treatment in the past twelve months.
- Met standards for involuntary treatment within the past twelve months.
- Currently receiving or in need of mental health services and receiving or in need of services from two or more human service agencies or public systems such as Drug and Alcohol, Vocational Rehabilitation, Criminal Justice, etc.
- At least 3 missed community mental health service appointments or two or more face-to-face encounters with crisis intervention/emergency services personnel within the past twelve months, or documentation that the consumer has not maintained his/her medication regimen for a period of at least 30 days.
TRANSITION
Adults who received Resource Coordination, Intensive Case Management, or Blended Case Management services as children and were recommended by the provider and approved by the County Administrator or his/her designee or the Behavioral Health Managed Care Organization, as applicable, as needing Targeted Case Management services beyond the date of transition from child to adult.
WAIVER (if this option is selected acceptance is subject to review and approval)
An adult who needs to receive Targeted Case Management services, but does not meet the requirements identified above, may be eligible for Targeted Case Management upon review and recommendation by the County Administrator or his/her designee, or the Behavioral Health Managed Care Organization, as applicable.