HomeMy WebLinkAboutacbh-adult-outpatient-mental-health-services-referral-form-sept-2026
ADULT OUTPATIENT MENTAL HEALTH SERVICES REFERRAL FORM
If available, please attach InSyst facesheet, BH Screening Form & any additional clinical info to this
referral such as most recent Assessment, Treatment Plan, Psychiatric Evals, hospital intakes/discharge
summaries. Please note that a supervisor signature is required in order to process this referral. You
should receive a response from First Step within two business days of sending. Thank you.
DEMOGRAPHIC INFORMATION:
Date:
Client name:
Date of birth: Age: PSP#:
SSN: Client phone number:
Gender identification, preferred name & pronouns:
Address (if homeless include areas where individual spends time):
Primary language:
Cultural considerations:
Does this person have insurance: ☐ YES ☐ NO
If yes, what kind? ☐ Alameda County Medi-Cal ☐ Other County Medi-Cal:
☐ Medi-Medi ☐ Private:
☐ Other:
REFERRED BY:
Person completing form:
Phone and email:
Relationship to client:
Agency/Program (if applicable):
Is the individual receptive to this referral for services, please explain if not?
REASON FOR REFERRAL:
What led to this referral for mental health services:
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ADULT OUTPATIENT MENTAL HEALTH SERVICES REFERRAL FORM
Current mental health needs (include diagnosis(es) and symptoms if possible):
How are the mental health issues impacting individual’s functioning:
Brief history of mental health needs:
If individual is taking psychiatric medications, what medications and who is the prescriber:
OTHER RELEVANT INFORMATION:
Personal and environmental strengths:
Current living situation:
Other services person is receiving (provide agency name and type of service):
Mental health treatment history (type of treatment, location, provider, dates):
Current substance use, substance use history including any treatment:
Medical/physical health conditions and considerations:
Current safety concerns (within the last 90 days consider suicidality, violence towards others, grave
disability, other safety concerns):
Past safety concerns:
Criminal justice involvement currently and historically:
Other relevant information or co-occurring needs:
For Court and AFBH Staff only:
☐ 1370 ☐ Adult Forensic Behavioral Health
☐ 1370.01 ☐ Probation
☐ Court Advocacy Project ☐ Behavioral Health Court
[ ] DSH Diversion [ ] Other: ____________________
Contact person and contact info for the above check marks:
How soon is individual expected to be released to jail/returned to community? ________________
Is there at court order involved in release? If so, what is timeframe to arrange discharge from jail? __
Other information related to criminal justice involvement:
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ADULT OUTPATIENT MENTAL HEALTH SERVICES REFERRAL FORM
Please be sure to include a copy of the Alienist Report, PC Dec, or description of how crimes relate to
mental health and risk factors for similar future behavior.
TYPES OF SERVICES BEING REQUESTED:
☐ Therapy
☐ Medication support
☐ Clinical care coordination with psychiatry (Level 1)
☐ Intensive clinical care coordination with psychiatry (FSP)
☐ Outreach in order to engage in services (IHOT)
☐ Other (e.g. higher level of care):
Supervisor Approval for Request:
Supervisor Name:
Supervisor Signature: ______________________________________ Date:
Send completed form with accompanying materials to ACBH First Step:
Fax: 510-346-1083 or via email to: FirstStepReferrals@acgov.org
For questions call First Step at 1-800-491-9099
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