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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

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Form OMH 270 (4/04)

State 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
check box Hispanic check box White check box African check box American check box Native American/Alaskan Asian/Pacific Islander check boxOther (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, MI, Last Primary Contact?
Yes No		 County
Address, City, State, Zip Home Phone Work Phone
First, MI, Last Primary Contact?
Yes No		 County
Address, City, State, Zip Home Phone Work Phone
Current Providers
First, MI, Last Relationship County
Address, City, State, Zip Home Phone Work Phone
First, MI, Last Relationship County
Address, City, State, Zip Home Phone Work Phone
Background Information
Child’s living situation: (Check one box only)
01 check box Independent living
02 check box Two parent family
03 check box One parent family
04 check box Two parent adoptive family
05 check box One parent adoptive family
06 check box Other relative’s home
07 check box OCFS Family Foster Care
08 check box OMH CY Community Residence
09 check box Teaching Family Home
10 check box OCFS Group home		 11 check box OCFS Community Group Home
12check box Family Based Treatment
13 check box OCFS Therapeutic Foster Care
14 check box Crisis Residence
15 check box Runaway shelter
16 check box Residential school (SED)
17 check box Residential Treatment Center (OCFS)
18 check box Residential Treatment Facility (OMH)
19 check box Psychiatric inpatient care - unspecified
20 check box OCFS/DRS Facility		 21 check box Jail
22 check box Homeless/streets
24 check box Grandparent(s)
25 check box Private psychiatric inpatient- Article 31
26 check box General hospital psych inpatient- Article 28
27 check box State psychiatric inpatient
88 check boxOther specify
99 check box Unknown
Child’s custody status: (Check one box only)
01 check box Biological Parents
02 check box Adoptive Parent
03 check box Grandparent(s)		 04 check box Other Family/ Legal Guardians
05 check box Local DSS		 06 check box Emancipated Minor
88 check box Other
Highest level of education completed: (Check one box only)
01 check box Kindergarten
02 check box First
03 check box Second
04 check box Third
05 check box Fourth
06 check box Fifth
07 check box Sixth 		08 check box Seventh
09 check box Eighth
10 check box Ninth
11 check box Tenth
12 check box Eleventh
14 check box Ungraded – Elementary		 15 check box Ungraded – Middle School
16 check box Ungraded – High School
17 check box College
18 check box Graduate
19 check box Post Graduate
99 check box Unknown
School District:
Child’s Educational Placement: (Check one box only)
01 check box Regular class in age-appropriate grade
02 check box Regular class, above grade level
03 check box Regular class, but behind at least one grade
04 check box Special class for students with handicapping conditions
05 check box Residential school for the educationally (emotionally) handicapped
06 check box Vocational training only
07 check box Part time vocational/educational
09 check box High school graduate/GED		 10 check box Day Treatment
11 check box Home instruction
12 check box BOCES
13 check box College
77 check box Not enrolled in school
88 check box Other specify
99 check box Unknown
Home School Name: Current School Name: Date of Last IEP:
Committee on Special Education Status:
02 check box Emotionally disturbed
03 check box Learning disabled
04 check box Sensory impaired 		05 check box Physically disabled
06 check box Other health impaired
07 check box Multiply handicapped 		77 check box None
99 check box Unknown
Child’s IQ: Verbal Score– Performance Score: Full Scale Score: Date:
Child’s Legal Status: (Check one box only)
01 check box PINS
02 check box PINS Diversion
03 check box Juvenile delinquent		 04 check box Juvenile delinquent – restricted
05 check box Juvenile offender
77 check box None		 88 check box Other specify
99 check box Unknown
Income or benefits child is currently receiving: (Check all that apply)
01 check box Supplemental Security Income (SSI)
02 check box Social Security Disability Income (SSDI)
03 check box Veteran benefit
04 check box Social Security retirement, survivor’s or dependent’s (SSA)
05 check box Any public assistance cash program: Family Assistance (TANF), Safety Net, Temporary Disability
06 check box Medicaid
07 check box Medicare 		08 check box Medication grant
09 check box Private insurance, employer coverage, no third party insurance
10 check box Other (please specify)
Other Benefits (Annual or Monthly Amounts)
Insurance Type, Policy Holder, Policy Number: Citizenship: Yes  No Legal Alien: Yes No

Date of Entry:

Country of Origin:

Alien ID number:
Income:
HI number, currently enrolled? Yes No
Child Support (Specific Amounts): Yes No
Resources/Assets (savings bonds, trust) type & amount:
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
01 check box Problems with primary support group
02 check box Problems related to the social environment
03 check box Educational problems
04 check box Occupational problems
05 check box Housing problems		 06 check box Economic problems
07 check box Problems with access to health care services
08 check box Problems related to access with the legal system/crime
09 check box Other psychosocial and environmental problems
Axis V: Global Assessment of Functioning (GAF):
Who Made the Diagnosis: Date of Diagnosis:
Symptoms and Behavior
Using the scale below, indicate the degree of the child’s symptoms/behaviors.
    Not Evident
0		 Mild
1		 Moderate
2		 Marginally Severe
3		 Severe
4		 Unknown
9
Scale
0.        Not Evident Child does not display this symptom/behavior
1.        Mild This symptom/behavior exists, but there is no impairment (loss of effectiveness) in carrying out daily activities or in meeting major role requirements.
2.        Moderate 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
4.        Severe This symptom-behavior exists Definite impairment 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  		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            
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		 54 Peer Interactions            
55 Hyperactive            
56 Impulsive            
57 Self-injury            
58 Runaway            
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.
    Never
0		 Rarely
1		 Sometimes
2		 Often
3		 Always
4		 Unknown
9
Scale
0.        Never This behavior not observed or reported.
1.        Rarely The child has engaged in behavior once in the past 18 months.
2.        Sometimes The child has engaged in behavior two times in the past 18 months.
3.        Often The child has engaged in behavior five times in the past 18 months.
4.        Always The child has routinely engaged in behavior more than five times in the past 18 months.
9.        Unknown		 44 Suicide Attempts            
45 Destruction of Property            
46 Fire Setting            
47 Cruelty to Animals            
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.
2.        Moderate 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.
4.        Severe 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
  Not Evident
0		 Mild
1		 Moderate
2		 Marginally Severe
3		 Severe
4		 Unknown
9
55 Self Care            
56 Social Relationships/Functioning            
57 Cognitive Functioning/Communication            
58 Self Direction            
59 Motor Functioning            
Physical Health Information
Current Medical Conditions: Any Medical Alerts:
Drugs for Medical Conditions:
Is Child taking medications for psych condition? Yes No Medication Name: (if yes is checked)
Child’s Treatment and Services History
Scale
0.         Never
1.         Not at all in past six months
2.         One or more times in the past 6 months, but not in the past 3 months
3.         One or more times in the past 3 months, but not in the past month
4.         One 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 check box Intensive Case Management
02 check box Service coordination/case management
03 check box Individualized care coordination
04 check box Clinic treatment
05 check box Private/individual therapy
06 check box Crisis response services
07 check box Home Based Crisis Intervention
08 check box Day Treatment
09 check box Respite
10 check box Medication management 		11 check box Vocational training
12 check box ADL or Independent living skills
13 check box Alcohol abuse treatment
14 check box Substance abuse treatment
15 check box Family Support Services
16 check box Transportation
17 check box After school/weekend program
18 check box Specialized summer program
19 check box Specialized educational services
20 check box Speech & language therapy
21 check box Mentoring 		22 check box Flexible funding
23 check box Foster Care
24 check box State psychiatric facility
25 check box Private psychiatric facility
26 check box General hospital psychiatric inpatient
27 check box OMRDD Developmental Center
28 check box Intensive in home
29 check box CCSI
30 check box Supportive Case Manager
31 check box Residential Treatment Facility
88 check box Other specify
Referral
Referral Source to SPOA:
01 check box Family/legal guardian
02 check box Self
03 check box School/education system
04 check box State-operated inpatient program
05 check box Local hospital acute inpatient unit (psychiatric & general hospital)
06 check box Juvenile justice system		 07 check box Social Services
08 check box Other mental health program
09 check box Physician
11 check box Emergency room
12 check box Private psychiatric inpatient hospital
 13 check box Residential Treatment Facility
14 check box Community residence
15 check box Intensive Case Management
16 check box OMRDD
88 check box Other specify
Services Child referred to SPOA for: (Check all that apply)
01 check box Intensive Case Management
02 check box Service coordination/case management
03 check box Individualized care coordination
04 check box Clinic treatment
05 check box Private/individual therapy
06 check box Crisis response services
07 check box Home Based Crisis Intervention
08 check box Day Treatment
09 check box Respite
10 check box Medication management		 11 check box Vocational training
12 check box ADL or Independent living skills
13 check box Alcohol abuse treatment
14 check box Substance abuse treatment
15 check box Family Support Services
16 check box Transportation
17 check box After school/weekend program
18 check box Specialized summer program
19 check box Specialized educational services
20 check box Speech & language therapy
21 check box Mentoring 		22 check box Flexible funding
23 check box Foster Care
24 check box State psychiatric facility
25 check box Private psychiatric facility
26 check box General hospital psychiatric inpatient
27 check box OMRDD Developmental Center
28 check box Intensive in home
29 check box CCSI
30 check box Supportive Case Manager
31 check box Residential Treatment Facility
88 check box 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
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 accordance 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, (insert Parent/legal Guardian/ACS/Foster Care), 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 (Insert Child’s Name) for possible placement 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.
  1. 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 information 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 (Insert Name of Facility/Program). 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 requirements of the federal privacy protection regulations found under 45 CFR (164.524)
Please select one choice from either B-1 or B-2:

B-1. One-time Use/Disclosure: I hereby 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 hereby 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)

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