HomeMy WebLinkAbouttbs-referral-form-description-and-referral-process-englishPage 1 ak 5/8/24
2000 Embarcadero Cove,
Suite 400
Oakland, CA 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
Therapeutic Behavioral Services
Description and Referral Process
Therapeutic Behavioral Services (TBS) are supplemental specialty mental health services covered
under the EPSDT benefit. TBS is an intensive, individualized, one-to-one behavioral mental health
service available to children and youth under the age of 21 with serious emotional challenges and
their families and have full-scope Medi-Cal.
TBS is never a primary therapeutic intervention and is always used in conjunction with a primary
specialty mental health service. TBS is designed to support clients to be successful in their current
environment or to transition to a lower level of care.
TBS are adjunct, short-term, one-to-one behavior intervention services for eligible full- scope Medi-
Cal clients who receive services from a specialty mental health provider (SMHP). These clients also
have serious emotional problems and are experiencing a stressful transition or life crisis and need
additional mental health services, i.e., TBS, to prevent placement in a group home/Short Term
Residential Treatment Program (STRTP) or a locked facility for treatment of their mental health
needs. TBS is also utilized to facilitate transition from any of those levels to a lower level of
residential care. TBS is decreased when indicated and discontinued when the identified target
behavioral goals have been achieved or, in the clinical judgment of the TBS provider, will not be.
Our TBS providers are comprised of both professional and paraprofessional personnel.
Professional staff may be licensed, interns working toward licensure, or license- waivered. To
provide integrated and comprehensive services, client information may be shared on a need-to-
know basis for supervision and consultation. Client information may also be exchanged among
participants of designated partner agencies who are involved in delivering this comprehensive
service as a collaborative team. Information disclosed by you, the youth or other family members
while participating in TBS is generally confidential, unless exceptions to confidentiality apply.
Exceptions to confidentiality include, but are not limited to, reporting suspected child abuse, or
expressed threats of violence towards self or an identifiable victim, and certain legal proceedings.
Referral Process
The process by which Primary Specialty Mental Health Providers (SMHP) can make referrals to TBS
on behalf of their clients is by discussing the service with their clients and guardians and
documenting the linkage to TBS services in a TCM progress note which may also necessitate
updating the TCM care plan. The SMHP should then submit the TBS referral packet including the
completed referral form, the MH Assessment, and the Problem List to the ABH Administrator for
review and authorization. Upon ABH approval, one of our contracted TBS Providers will begin their
functional behavioral assessment following with providing direct services.
Page 2 ak 5/8/24
2000 Embarcadero Cove,
Suite 400
Oakland, CA 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
Therapeutic Behavioral Services (TBS) Referral Form
Instructions: Please fill out completely and attach
Current Mental Health Assessment and Problem List
Email to: TBSCoordinator@acgov.org or Fax to: 1-888-818-1501
Client’s Name: Date of Birth:
Client’s Preferred Name: Ethnicity:
Address:
Gender
Identity
Male Transgender
Male Non-Binary
Gender
Pronouns
He/Him
She/Her
Female Transgender
Female Other They/Them
Full-Scope Medi-Cal? Yes No (not eligible for TBS)
Referring party is a Specialty Mental Health Service (SMHS) Medi-Cal Billing Provider? Yes No (not eligible for TBS)
Client’s Preferred Language: Social Security Number
Guardian’s Preferred Language:
CERTIFIED CLASS MEMBERSHIP
Client must meet at least ONE of the following criteria. Check all that apply:
Currently in a STRTP and/or locked treatment facility
Being considered by the County for a STRTP and/or locked treatment center facility:
X
One psychiatric hospitalization in the preceding 24 months related to current presenting disability:
Date(s) of Hospitalization:
Previously received TBS while a member of the certified class:
At risk of psychiatric hospitalization:
Signature of Specialty Mental Health Provider (SMHP) Representative:
X
Page 3 ak 5/8/24
2000 Embarcadero Cove,
Suite 400
Oakland, CA 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
SERVICE NEED Check one:
In my clinical judgment, it is highly likely that without the additional short-term support of TBS, this
client:
Will need to be placed out of home or in a higher level of residential care, including acute care,
because of the change in the client’s behaviors or symptoms which jeopardize placement.
Needs this additional support to transition to a lower level of residential placement. Although
the client may be stable in the current placement, a change in behavior or
symptoms is expected and Therapeutic Behavioral Services are needed to stabilize the client in the
None of the above applies. (Not eligible for TBS)
phone contact:
Signature of Mental Health Provider: X
Printed Name of Mental Health Provider:
Email: Phone:
Agency: Fax:
PRIMARY RESIDENCE(S) FOR CLIENT RECEIVING TBS
Contact Name Address Phone
Family Home 1:
Family Home 2:
Foster Home:
Foster Family Agency:
STRTP /
Other:
Page 4 ak 5/8/24
2000 Embarcadero Cove,
Suite 400
Oakland, CA 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
CURRENT PROBLEM BEHAVIORS Check all that apply:
Self-injurious behavior Property damage Verbal aggression
Threat to others Physical aggression Withdrawal, isolates self
Threat to self Disordered eating Sexual behaviors
Disregard for rules (e.g.,
limits around safety,
eloping, hygiene)
Severe restrictions on activities of daily
fear to go outside, uncontrollable crying,
hyperawareness, hygiene)
page 1:
Client is currently receiving mental health services from:
Fred Finch Lincoln La Cheim Seneca Victor Other:
ICD Code: DX:
ICD Code: DX:
Page 5 ak 5/8/24
2000 Embarcadero Cove,
Suite 400
Oakland, CA 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
Program Description
TBS is always provided in conjunction with other specialty mental health services such as individual
therapy, family therapy, or wraparound services. TBS is short-term, one-to-one behavior intervention
services for eligible full-scope Medi-Cal clients.
Caregivers have been informed of, and agree with, referral being made.
minimum weekly caregiver participation/involvement.
CONTACT INFORMATION:
Please enter the name of person/agencies involved in your child/youth’s comprehensive treatment:
Mental Health Provider: Phone:
Parent / Caregiver:
Child Welfare Worker (CWW):
Probation Officer: Phone:
Case Manager:
Regional Center Case Mgr: Phone:
STRTP Staff: Phone:
School Staff:
ICC Provider: Phone:
Primary Care Physician:
Other:
REQUIRED ATTACHMENTS:
Current Mental Health Assessment
Client Problem List
Signature of person
: X Date:
Printed name of person
completing form: Phone:
Agency: Fax:
Page 6 ak 5/8/24
2000 Embarcadero Cove,
Suite 400
Oakland, CA 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
Reason(s):
For office use only: ABH Therapeutic Behavioral Services (TBS) Referral Form
Client’s Name:
ABH DETERMINATION
Client meets TBS Eligibility
Client does NOT meet TBS criteria
X
ABH Administrator Signature Printed Name Date