Form Omh 270 PDF Details

The Form OMH 270, devised by the State of New York Office of Mental Health, serves as a comprehensive Universal Referral Form, primarily utilized for streamlining the referral processes within the context of mental health services. Noteworthy for its thorough approach to capturing a wide array of information, this form balances a combination of CAIRS Core and Optional Elements, along with specific sections dedicated to paper transfer. It meticulously gathers client information, encompassing personal identifiers, demographic details, and a nuanced breakdown of the child's current living situation, educational background, legal status, and an extensive overview of their physical and mental health status. The form's design reflects a keen understanding of the multifaceted nature of mental health care, aiming to provide a holistic snapshot of the child's needs, both medical and psychosocial. Furthermore, this form delves into the child's treatment and service history, current medication usage, and the frequency of specific behaviors or symptoms over a period, thereby offering a detailed baseline for evaluating the child's ongoing needs. The inclusion of sections on the child and family's strengths alongside the perceived needs underscores a strengths-based approach in care planning. Critical for facilitating targeted referrals within New York State's Office of Mental Health Services, the OMH 270 enables efficient communication between various stakeholders, including families, legal guardians, schools, and healthcare providers, ensuring a coordinated effort in addressing the complex needs of children requiring mental health services.

QuestionAnswer
Form NameForm Omh 270
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesB-2, omh cairs, OMRDD, New_York

Form Preview Example

Form OMH 270 (4/04) page 1State of New York Office of Mental Health

SPOA Universal Referral Form

Bolded – CAIRS Core Elements Non-Bold – CAIRS Optional Elements Italic type – Paper Transfer

Client Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s First Name

 

 

 

 

 

 

Middle initial

Last name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Gender

Male Female

Child’s Social Security Number

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

Medicaid ID 1

 

 

Medicaid ID 2

 

 

 

Primary Language

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Race

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hispanic White African American

Native American/Alaskan Asian/Pacific Islander

Other (Specify) __________

County of SPOA (Fiscal) Responsibility

 

 

 

County of Residence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mother’s name, (First, MI, Last)

 

 

 

 

Primary Contact?

Yes

No

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, City, State, Zip

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father’s name, (First, MI, Last)

 

 

 

 

Primary Contact?

Yes

No

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, City, State, Zip

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

Has family been referred for other services?

Yes No

Please list services:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are parents legal guardians?

Yes No

If no, please list guardian below in “Other Significant Contacts.”

 

 

 

 

 

 

 

 

Other Significant Contacts– Please list other significant contacts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name, MI, Last Name

 

 

 

 

 

 

 

Primary Contact?

Yes

No

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, City, State

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name, MI, Last Name

 

 

 

 

 

 

 

Primary Contact?

Yes

No

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, City, State

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Providers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name, MI, Last Name

 

 

 

 

 

 

 

Relationship

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, City, State

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name, MI, Last Name

 

 

 

 

 

 

 

Relationship

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, City, State

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name, MI, Last Name

 

 

 

 

 

 

 

Relationship

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, City, State

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form OMH 270 (4/04) page 2

State of New York

 

Office of Mental Health

SPOA Universal Referral Form

Background Information

Child’s living situation: (Check one box only)

01

Independent living

11

DFY Community Group Home

21

Jail

02

Two parent family

12

Family Based Treatment

22

Homeless/streets

03

One parent family

13

OCFS Therapeutic Foster Care

24

Grandparent(s)

04

Two parent adoptive family

14

Crisis Residence

25

Private psychiatric inpatient- Article 31

05

One parent adoptive family

15

Runaway shelter

26

General hospital psych inpatient- Article 28

06

Other relative’s home

16

Residential school (SED)

27

State psychiatric inpatient

07

OCFS Family Foster Care

17

Residential Treatment Center (OCFS)

88

Other specify

08

OMH CY Community Residence 18

Residential Treatment Facility (OMH)

99

Unknown

09

Teaching Family Home

19

Psychiatric inpatient care - unspecified

 

 

10

OCFS Group home

20

OCFS/DRS Facility

 

 

Child’s custody status: (Check one box only)

01

Biological Parents

04

Other Family/Legal Guardians

06

Emancipated Minor

02

Adoptive Parent

05

Local DSS

88

Other

03

Grandparent(s)

 

 

 

 

Highest level of education completed: (Check one box only)

01

Kindergarten

08

Seventh

15

Ungraded – Middle School

02

First

09

Eighth

16

Ungraded – High School

03

Second

10

Ninth

17

College

04

Third

11

Tenth

18

Graduate

05

Fourth

12

Eleventh

19

Post Graduate

06

Fifth

14

Ungraded – Elementary

99

Unknown

07

Sixth

 

 

 

 

 

 

 

 

 

School District:

 

 

 

 

 

 

 

Child’s Educational Placement: (Check one box only)

 

 

01

Regular class in age-appropriate grade

10

Day Treatment

02

Regular class, above grade level

 

 

11

Home instruction

03

Regular class, but behind at least one grade

12

BOCES

04

Special class for students with handicapping conditions

13

College

05

Residential school for the educationally (emotionally) handicapped

77

Not enrolled in school

06

Vocational training only

 

 

88

Other specify

07

Part time vocational/educational

 

 

99

Unknown

09

High school graduate/GED

 

 

 

 

Home School Name:

Current School Name:

Date of Last IEP:

Committee on Special Education Status:

02

Emotionally disturbed

05

Physically disabled

 

77

None

03

Learning disabled

06

Other health impaired

 

99

Unknown

04

Sensory impaired

07

Multiply handicapped

 

 

 

 

 

 

 

 

 

 

 

Child’s IQ:

 

Verbal Score– Performance Score:

 

Full Scale Score:

 

Date:

 

 

 

 

 

 

 

Child’s Legal Status: (Check one box only)

 

 

 

 

01

PINS

 

04

Juvenile delinquent – restricted

88

Other specify

02

PINS Diversion

 

05

Juvenile offender

 

99

Unknown

03

Juvenile delinquent

77

None

 

 

 

 

Income or benefits child is currently receiving: (Check all that apply)

01

Supplemental Security Income (SSI)

08

Medication grant

02

Social Security Disability Income (SSDI)

09

Private insurance, employer coverage, no third party insurance

03

Veteran benefit

10

Other (please specify) ________________________________

04

Social Security retirement, survivor’s or dependent’s (SSA)

 

 

05

Any public assistance cash program: Family Assistance (TANF), Safety Net, Temporary Disability

06

Medicaid

 

 

07

Medicare

 

 

Form OMH 270 (4/04) page 3

 

State of New York

 

 

Office of Mental Health

SPOA Universal Referral Form

 

 

 

 

Other Benefits (Annual or Monthly Amounts)

 

 

 

 

 

Insurance Type, Policy Holder, Policy Number:

Citizenship: Yes No

Legal Alien: Yes No

Income:

 

Date of Entry: ___________________

 

 

 

HI number, currently enrolled? Yes No

 

Country of Origin: ________________

Child Support (Specific Amounts): Yes No

 

Alien ID number: _________________

Resources/Assets (savings bonds, trust) type & amount:

 

 

 

 

 

TANE Eligibility (low income, public assistance):

 

 

Diagnosis Information

Axis I Diagnoses: clinical disorders, other conditions that may be a focus of clinical attention – Up to 4 diagnoses may be entered. Please list Axis 1 Primary Diagnosis first.

Axis II Diagnosis: personality disorders, mental retardation (if any) – Up to 4 diagnoses may be entered

Axis III Diagnosis: general medical conditions (if any) – Up to 4 diagnoses may be entered

Axis IV Diagnosis: psychosocial and environmental problems

1

Problems with primary support group

6

Economic problems

2

Problems related to the social environment

7

Problems with access to health care services

3

Educational problems

8

Problems related to access with the legal system/crime

4

Occupational problems

9

Other psychosocial and environmental problems

5

Housing problems

 

 

Axis V: Global Assessment of Functioning (GAF):

Who Made the Diagnosis:

Symptoms and Behavior

Date of Diagnosis:

Using the scale below, indicate the degree of the child’s symptoms/behaviors.

SCALE

0NOT EVIDENT Child does not display this symptom/ behavior

1MILD This symptom/behavior exists, but there is no impairment (loss of effectiveness) in carrying out daily activities or in meeting major role requirements.

2MODERATE This symptom/behavior exists. This child maintains an appropriate level of functioning in daily activities and major roles only with difficulty and increased effort and support.

3MARGINALLY SEVERE This symptom/behavior exists. There is definite impairment in carrying out daily activities and/or performing major roles. Major roles are able to be perform

4SEVERE This symptom-behavior exists Definite impair- ment exists in daily activities. The child is unable to per- form one or more major role at any level. The child may not be allowed to remain in one or more major roles due to severity of symptom/behavior.

9 UNKNOWN

DURATION SCALE

1= in past 30 days 2= with in 90 days

3= with in past 6 months 4= with in past year 5= over 1 year

 

 

 

 

 

Margin-

 

 

 

 

Not

 

Mod-

ally

 

 

 

 

Evident

Mild

erate

Severe

Severe

Unknown

 

 

0

1

2

3

4

9

35

Suicidal Ideation

36

Psychotic Symptoms

37

Depression

38

Anxiety

39

Phobia

40

Danger to self

41

Danger to others

42

Temper Tantrums

43

Sleep Disorders

44

Enuresis/Encopresis

45

Physical Complaints

46

Alcohol abuse

47

Drug abuse

48

Developmental Delays

49

Sexually inappropriate

50

Sexually Aggressive

51

Verbally Aggressive

52

Physically Aggressive

53

Eating Disorder

54

Peer Interactions

55

Hyperactive

56

Impulsive

57

Self-injury

58

Runaway

Form OMH 270 (4/04) page 4

State of New York

 

Office of Mental Health

SPOA Universal Referral Form

Using the scale below, indicate the level that most accurately reflects the frequency with the child engaged in the following behaviors in the past 18 months.

SCALE

0 NEVER This behavior not observed or reported.

1RARELY The child has engaged in behavior once in the past 18 months.

2SOMETIMES The child has engaged in behavior two times in the past 18 months.

3OFTEN The child has engaged in behavior five times in the past 18 months.

4ALWAYS The child has routinely engaged in behavior more than five times in the past 18 months.

9 UNKNOWN

 

 

 

 

Some-

 

 

 

 

 

Never

Rarely

times

Often

Always

Unknown

 

 

0

1

2

3

4

9

44

Suicide Attempts

45

Destruction of Property

46

Fire Setting

47

Cruelty to Animals

Functioning

SCALE

0 NOT EVIDENT Child does not display this symptom/behavior

1 MILD This symptom/behavior exists, but there is no impairment (lost of effectiveness) in carrying out daily activities or in meeting major role requirements.

2MODERATE This symptom/behavior exists. This child maintains an appropriate level of functioning in daily activities and major roles only with difficulty and increased effort and support.

3 MARGINALLY SEVERE This symptom/behavior exists There is definite impairment in carrying out daily activities and/or performing major roles. Major roles are able to be perform.

4SEVERE This symptom/behavior exists Definite impairment exists in daily activities. The child is unable to perform one or more major role at any level. The child may not be allowed to remain in one or more major roles due to severity of symptom/behavior

9 UNKNOWN

 

 

 

Margin-

 

 

Not

 

Mod-

ally

 

 

Evident

Mild

erate

Severe

Severe

Unknown

0

1

2

3

4

9

55Self Care

56Social Relationships/Functioning

57Cognitive Functioning/Communication

58Self Direction

59Motor Functioning

Physical Health Information

Current Medical Conditions:

Any Medical Alerts:

Drugs for Medical Conditions:

Is Child taking medications for psych condition? ノ ノ Yes No

Child’s Treatment and Services History

Medication Name: (if yes is checked)

SCALE

0 Never

1 Not at all in past six months

2One or more times in the past 6 months, but not in the past 3 months

3One or more times in the past 3 months, but not in the past month

4One or more times in the past month, but not in the past week

5 One or more times in the past week

 

(Enter number. Please enter 0 for none.)

Psychiatric hospitalization in last 12 months

___________________

Psychiatric hospitalization in last 6 months

___________________

Emergency Room visits in last 12 months- NYC only

___________________

Emergency Room visits in last 6 months

___________________

Arrests in last 6 months

___________________

Incarceration in last 6 months

___________________

How frequently was this recipient a victim of sexual or physical abuse?

History of Past and Present Services: (Check all that apply)

01

Intensive Case Management

11

Vocational training

22

Flexible funding

02

Service coordination/case management

12

ADL or Independent living skills

23

Foster Care

03

Individualized care coordination

13

Alcohol abuse treatment

24

State psychiatric facility

04

Clinic treatment

14

Substance abuse treatment

25

Private psychiatric facility

05

Private/individual therapy

15

Family Support Services

26

General hospital psychiatric inpatient

06

Crisis response services

16

Transportation

27

OMRDD Developmental Center

07

Home Based Crisis Intervention

17

After school/weekend program

28

Intensive in home

08

Day Treatment

18

Specialized summer program

29

CCSI

09

Respite

19

Specialized educational services

30

Supportive Case Manager

10

Medication management

20

Speech & language therapy

31

Residential Treatment Facility

 

 

21

Mentoring

88

Other specify

Form OMH 270 (4/04) page 5

 

 

 

State of New York

 

 

 

 

 

Office of Mental Health

 

 

SPOA Universal Referral Form

 

 

 

 

 

 

 

Referral

 

 

 

 

 

 

 

 

 

Referral Source to SPOA:

 

 

 

 

01

Family/legal guardian

07

Social Services

13

Residential Treatment Facility

02

Self

08

Other mental health program

14

Community residence

03

School/education system

09

Physician

15

Intensive Case Management

04

State-operated inpatient program

11

Emergency room

16

OMRDD

05

Local hospital acute inpatient unit

 

(psychiatric & general hospital)

88

Other specify

06

Juvenile justice system

12

Private psychiatric inpatient hospital

 

 

Services Child referred to SPOA for: (Check all that apply)

01

Intensive Case Management

11

Vocational training

22

Flexible funding

02

Service coordination/case management 12

ADL or Independent living skills

23

Foster Care

03

Individualized care coordination

13

Alcohol abuse treatment

24

State psychiatric facility

04

Clinic treatment

14

Substance abuse treatment

25

Private psychiatric facility

05

Private/individual therapy

15

Family Support Services

26

General hospital psychiatric inpatient

06

Crisis response services

16

Transportation

27

OMRDD Developmental Center

07

Home Based Crisis Intervention

17

After school/weekend program

28

Intensive in home

08

Day Treatment

18

Specialized summer program

29

CCSI

09

Respite

19

Specialized educational services

30

Supportive Case Manager

10

Medication management

20

Speech & language therapy

31

Residential Treatment Facility

 

 

21

Mentoring

88

Other specify

Please describe why child requires the highest level of service that SPOA provides:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

List Child’s Strengths: (Enter as many as desired)

_____________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

List of Family/Caregiver Strengths: (Enter as many as desired)

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Name of Person Referring Child to SPOA:

Title:

Signature of Person Referring Child to SPOA:

Phone:

Date of Referral to SPOA

Form OMH 270 (4/04) page 6

State of New York

 

Office of Mental Health

SPOA Universal Referral Form

AUTHORIZATION FOR RELEASE OF INFORMATION

This authorization must be completed by the patient or his/her personal representative to use/disclose protected health information, in accor- dance with State and Federal laws and regulations. A separate authorization is required to use or disclose confidential related information.

PART 1: Authorization for Release of Information

Description of Information to be Used/Disclosed:

I, ____________________________________________________________________, consent to release clinical information to the

Single Point of Access (SPOA). I understand that the SPOA will review and evaluate the information to determine eligibility for services in Home and Community Based Services Waiver, Case Managements Services, Family Based Treatment or Community Residence.

Purpose or Need for Information:

1.This information is being requested by:

The individual or his/her personal representative; or

Other (please describe) _______________________________________________________________________________

2.The purpose of the disclosure is (please describe):

It is understood that this information will be used to evaluate ________________________________________ for possible place-

ment with HCBS Wavier, Case Management, Family Based Treatment or Community Residence. Upon acceptance, my child will be receiving services from one of the above.

To: Name, Address, & Title of Person/Organization/Facility Program to Which this Disclosure is to be Made

Note: If the same information is to be disclosed to multiple parties for the same purpose, for the same period of time, this authorization will apply to all parties listed here.

A.I authorize the SPOA to release clinical information and make recommendations for the appropriate program for possible enrollment. I also understand that the SPOA may recommend other appropriate programs/services, such as Residential Treatment Facility, the Coordinated Children’s Services Initiative, or the Parent Resource Center. I hereby permit the use or disclosure of the above infor- mation to the Person/Organization/Facility/Program(s) identified above. I understand that:

1.Only this information may be used and/or disclosed as a result of this authorization.

2.This information is confidential and cannot legally be disclosed without my permission.

3.If this information is disclosed to someone who is not required to comply with federal privacy protection regulations, then it may be redisclosed and would no longer be protected.

4.I have the right to revoke (take back) this authorization at any time. My revocation must be in writing on the form provided to me by ______________________________________________________________. I am aware that revocation will not be effective if the persons I have authorized to use and/or disclose my protected health information have already taken action because of my earlier authorization.

5.I do not have to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from the New York State Office of Mental Health, nor will it affect my eligibility for benefits.

6.I have a right to inspect and copy my own protected health information to be used and/or disclosed in accordance with the require- ments of the federal privacy protection regulations found under 45 CFR (164.524).

Continue on Next Page

Form OMH 270 (4/04) page 7

State of New York

 

Office of Mental Health

SPOA Universal Referral Form

Please select one choice from either B-1 or B-2:

B-1. One-time Use/Disclosure: I herby permit the one-time use or disclosure of the information described above to the person/ organization/facility/program identified above.

My authorization will expire:

When acted upon;

90 Days from this Date;

B-2. Periodic Use/Disclosure: I herby permit the periodic use or disclosure of the information described above to the person/ organization/facility/program identified above.as often as necessary to fulfill the purpose identified above.

My authorization will expire:

When I am no longer receiving services from one of the intensive high end mental health services;

One Year from this Date;

Other ___________________________________________________________________________________

C. Patient Signature: I certify that I authorize the use of my medical/mental health information as set forth in this document.

___________________________________________________________________________ ________________________________

Signature of Patient or Personal Representative

Date

___________________________________________________________________________

 

Patient’s Name (Printed)

 

___________________________________________________________________________

 

Personal Representative’s Name (Printed)

 

____________________________________________________________________________________________________________________

Description of Personal Representative’s Authority to Act for the Patient (required if Personal Representative signs Authorization)

D.Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the Personal Representative

WITNESSED BY: __________________________________________________________

________________________________

Staff person’s name and title

Date

Authorization Provided To: ____________________________________________

 

 

 

To be Completed by Facility:

 

___________________________________________________________________________

________________________________

Signature of Staff Person Using/Disclosing Information

Date Released

___________________________________________________________________________

 

Title

 

PART 2: Revocation of Authorization to Release Information

I hereby revoke my authorization to use/disclose information indicated in Part 1, to the Person/Organization/Facility Program whose name and address is:

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

I hereby revoke my authorization to use/disclose information indicated in Part 1, to the Person/Organization/Facility Program whose name and address is:

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________

________________________________

Signature of Patient or Personal Representative

Date

___________________________________________________________________________

 

Patient’s Name (Printed)

 

___________________________________________________________________________

 

Personal Representative’s Name (Printed)

 

____________________________________________________________________________________________________________________

Description of Personal Representative’s Authority to Act for the Patient (required if Personal Representative signs Authorization)