How To Make a Referral

Please complete the form as thoroughly as possible. This information serves ONLY to help connect the resources with the need. It does not determine admittance. Mostly, we have same day placement.

Referral process specific to the HCBS-AMH program is facilitated through the Local Mental Health Authority. Once referred, the applicant is evaluated and HHSC verifies eligibility. If they're eligible, the person is enrolled in the program by HHSC. We can help with this process.

Referral Form
Please indicate unknown when appropriate

First and Last Name

Birthday

Contact phone number

Who is the referral source?

When is placement needed?

What is your primary insurance?

List primary psych diagnosis. List primary dx first.

List all medical diagnosis. List primary dx first.

What triggers the psych diagnosis?

How many ER visits, for any reason, in the past 3 years?

Do you have any current substance use issues?

Yes

Unknown

If so what?

Is there a history of any substance use?

Yes

Unknown

If so, what substance? (meth, nicotine, alcohol, crack, etc.)

What are your mobility restrictions?

Are there any bowel OR bladder incontinence issues?

Please explain why the applicant is moving from the previous residence?

How many arrest in the past 3 years for any reason ?

Whis is the income amount, income source, and payee? Please describe any special considerations

Is there any issues with medication compliance? If so explain.

We have been notified of your request. You will hear from us soon.

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Referral Form Please indicate unknown when appropriate

Referral Form
Please indicate unknown when appropriate