Health Home Referral Application : Your Community : Who We Help : Abbott House

Basic Demographics

Child's Name

First Name *

Middle

Last Name *

Phone Number

Date of Birth

Today's Date

Month

Day

Year

Child's Current Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Gender

Male
Female
Transgender Male
Transgender Female
Not Known

Is child in foster care?

Yes
No
Unknown

Language Preference

English
Spanish
Other

If other please specify below

Other Language

Insurance Information

Medicaid/CIN #

MCO Plan Name (if any)

Please upload a copy of Medicaid card if available

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Permission To Refer

You must identify that consent to refer has been obtained and who has given consent to refer. Please note that this can be verbal.

Parent
Guardian
Legally authorized representative
Individual is 18+
Individual is under 18, but is pregnant, married, or a parent

Date Permission obtained

Month

Day

Year

Legal Guardian

Medical Consenter's Name

First Name *

Last Name *

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Relationship to Child

Email Address

Medical Consenter's Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

County of Residence

Medical Consenter's Contact Phone Number

Medical Consenter's Additional Phone Number

Family/Residential Information

Is any other family member currently enrolled in a Health Home?

If YES, family member name

First Name

Last Name

Relationship to child

Health Home Name

Care management Agency

Health Home Eligibility Criteria

Please attach copy of documentation supporting any of these conditions if available.

Eligibility Type (only one required):

Two or More Chronic Conditions
Serious Emotional Distrubance
Complex Trauma

Appropriateness Criteria (Check all that apply)

At risk for adverse event (death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement)
Has inadequate social/family/housing support or serious disruptions in family relationships
Has inadequate connectivity with healthcare system
Does not adhere to treatments or has difficulty managing medications
Has recently been released from incarceration, placement, detention, or psychiatric hospitalization
Has deficits in activities of daily living, learning or cognition issues
Is concurrently eligible or enrolled, along with either their child or caregiver, in a Health Home

Supporting Documentation

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Referral Source

If Other, who?

Referral Organization

Personal Making Referral

First Name

Last Name

Contact Number for Person/Org Making Referral

Contact Email for Person / Org Making Referral

Caregiver Needs

Physical Health
Mental Health
Substance Abuse
Caregiver Stress
Supervision
Decision-Making
Informal Supports
Knowledge of Condition
Organization

Child Needs

Living Situation
Peer Interactions
Decision-Making
Recreational
Juvenile Justice/Legal
Sleep
School Achievement
School Behavior
School Attendance

Risk Behaviors

Suicide Risk
Self-Injurious Behavior
Other Self-Harm
Danger to Others
Sexual Inappropriateness
Bullying
Runaway
Eating Disturbance
Problematic Behavior

Behavioral Health

Psychosis
Attention
Impulsivity
Depression
Anxiety
Oppositional
Anger Control
Emotional Control
Attachment

Trauma Symptoms

Psychosis
Re-Experiencing
Hyperarousal
Avoidance
Numbing
Dissociation
Affective/Physiological Dysregulation

Care Manager Gender Preference

No Preference
Male
Female

Care Manager Language Preference

No Preference
English
Spanish

Notes