*If the youth is in Foster Care, please DO NOT COMPLETE THIS FORM and contact your local LDSS for further directions.

Is the youth in Foster Care?

No Yes

*Please DO NOT COMPLETE THIS FORM and contact your local LDSS for further directions.

Does the youth receive HCBS services?

No Yes

1. Identifying Information of Child/Youth Needing Services

First Name

Last Name

Date of Birth

Gender

Male Female Other

Street Address

City

Zip Code

County

Medicaid ID Number (CIN)

*If CIN is unavailable, provide SSN in "Medicaid ID Number (CIN)" field above

Phone Number (Include Area Code)

Indicate any need for language/interpretation services specify language spoken if other than English

2. Eligibility Category Information - Check All that Apply

In order to be eligible for Health Home services, the child/youth must be enrolled in Medicaid and must have

Two or more chronic conditions, or
- Click to view DOH Chronic Conditions List
Serious Emotional Disturbance (SED), or
- Click to view definition of SED
HIV/AIDS, or
Complex Trauma, or
Sickle Cell, or
HCBS

Eligibility Category Information

Two or more Chronic Conditions

Serious Emotional Disturbance

HIV/AIDS

Complex Trauma

Sickle Cell

HCBS

Please specify the diagnosis for Two or more Chronic Conditions selection:

*If Complex Trauma is being identified, the Complex Trauma Exposure Screen MUST be completed and submitted with the referral form to sufficiently prove eligibility. Before selecting this, please review the above options to ensure they do not already qualify in one of the other options.

3. Appropriateness Criteria- Check All that Apply

In addition, the child/youth must also have significant behavioral, medical, or social risk factors which can be addressed through care management.

Appropriateness Criteria

At risk for adverse event (death,disability,inpatient admission,mandated preventative services, etc)

Has inadequate social/family/housing support, or serious disruption in family relationships

Has inadequate connectivity with healthcare system

Does not adhere to treatments or has difficulty managing medications

Has recently been released from incarceration, placement, detention or psychiatric hospitalization

Has deficits in activities of daily living, learning or has cognition issues

Is concurrently eligible or enrolled, along with either their child or caregiver, in a health home

Please include additional details regarding each of the above selection(s) in the "Narrative" box below.

4. Narrative

Provide any additional information that may be helpful in assignment to a care management agency, including the SSN if the CIN was unavailable.

Narrative

Child/Youths Preferred/Recommended Care Management Agency (if any)

Attachment(s) - *You can select multiple files in the popup File Explorer window by holding the CTRL button

File attachments associated with the ticket.

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5. Consenter Information

Consent to make this referral must be obtained from the parent/guardian/legally authorized representative for children up until the age of 18. For children/youth ages 18-21, or that are married, a parent, or pregnant may provide consent on their own behalf.

Who has provided you with consent to make this referral to Encompass?

Parent

Guardian

Legally Authorize Representative

Child/Youth who is 18 years or older

Child/Youth who is under 18 years or but is a parent, or pregnant, or married

First Name

Last Name

Phone Number (Include Area Code)

6. Referrer Information

The organization you are with

*If "Other" is selected, please enter your organization below:

Your title or relationship to child/youth

Your phone number

Your name

Your email address

Verification Code

Encompass - Children's Community Referral Form