Mental Health and Substance Use Service Request Form

**Although not all fields on this form are required to submit, please include as much information as possible to make the referral process more efficient. If you include an email address, you will receive a confirmation email once your referral is submitted. Fields marked with a red asterisk (*) are required.**

If this is a life-threatening emergency, please do not complete this form and go to the nearest emergency department or call 911. If you have an immediate mental health or substance use need, please do not complete this form and call 916-875-1055.

Submitter Information

Request Date

Submitting Agency

* Submitting Entity Name

Per 42 CFR, this member agrees with this referral and submits to coordination of care to occur on their behalf.

Other Submitting Entity (If selected Other in the left dropdown)

* Requested Action

* Submitting Party/Contact Name

* Contact Phone

You can choose to include or exclude hyphens for phone numbers. Area code is required

Fax

Email Address

Client Information

* First Name

* Last Name

Birth Name (If different)

* Date of Birth

Format: mm/dd/yyyy

SSN

Formats: ###-##-####
#########
###-##-###P
###-##-###Q

Gender Identity

Maiden Name

Home Phone

Cell Phone

Street Address 1

Street Address 2

City

State

Zip Code

Primary Language

Race

Ethnic Origin

Mother's Maiden Name

Place of Birth

Country of Origin

Veteran Status

Housing Status

Caregiver Information

Parent/Caregiver/Conservator

Relationship

Primary Language

Mental Health Presenting Problems/Risk Factors(Check all that apply) (Please complete this portion only if you are seeking mental health services)

Substance Use and Drug History and Recent Events (Please complete remainder of form only if you are seeking substance use disorder services)

Reroll

**This field is case sensitive**

Anti-Social Behavior	Anxiety	Appetite Problems
Chronic Pain	Cries Excessively	Cruelty to Animals
Current Suicidal Ideation	Defiant/Oppositional	Delusions
Depressed Mood	Development Issues	Disorganized Thoughts
Does not Bond	Enuresis/Encopresis	Euphoric
Fire Setting	Frequent Nightmares	Grandiosity
Hallucinations	Hyperactivity	Inappropriate Guilt
Inappropriate Sexual Behavior	Irritability	Obsessive-Compulsive
Paranoia	Poor Concentration	Self-Injurious
Sleep Difficulties	Tantrums	Victimizes Others
Withdrawn

Mental Health and Substance Use Service Request Form

If this is a life-threatening emergency, please do not complete this form and go to the nearest emergency department or call 911. If you have an immediate mental health or substance use need, please do not complete this form and call 916-875-1055.

Submitter Information

Client Information

Caregiver Information

Mental Health Presenting Problems/Risk Factors(Check all that apply) (Please complete this portion only if you are seeking mental health services)

Associated Populations (Check all that apply):

CPS Involvement (Check all that apply):

Presenting Problems (Check all that apply):

Risk Factors (Check all that apply):

* Comments Regarding Presenting Problems / Risk Factors:

Current Medications & Prescriber:

Psychiatric History / Treatment History:

Additional Information:

* Services Requested:

Substance Use and Drug History and Recent Events (Please complete remainder of form only if you are seeking substance use disorder services)

Substance Use (Check all that apply):

Drug(s) of choice related to qualifying events (Check all that apply)

Criminal Justice History (Check all that apply)

Summary/Reason for referral

(Specific details and dates of the above checked boxes, includes AOD/SUD related history as well as treatment episodes, arrests, CPS, family & domestic violence, and current drug test results including failure to test(s))

Additional Information

(i.e., cultural issues, physical health problems, APS/CPS/Probation involvement, Description of qualifying events and all previous AOD/SUD history)