Form Omh 270 – Fill Out and Use This PDF

SPOA Universal Referral Form

Background Information

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

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

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

Committee on Special Education Status:

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

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

Axis V: Global Assessment of Functioning (GAF):

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

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.

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

Drugs for Medical Conditions:

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

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

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

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

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

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

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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:

ﾉThe individual or his/her personal representative; or

ﾉ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).

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