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DM / DA ODAS Confidential SHIRT Referral Form Client Name (Last, First, MI) Medicaid # Address: Telephone Number: Check one: ? DM ? DA ODAS REFERRAL SOURCE: Name of Community Mental Health Center

How to fill out dmhdaodas sbirt referral form

How to fill out dmhdaodas sbirt referral form?

1. The dmhdaodas sbirt referral form can be filled out by healthcare professionals, such as doctors, nurses, or counselors, who are conducting screenings for substance abuse and behavioral health disorders.
2. Start by providing basic information about the individual being referred, including their name, date of birth, address, and contact information.
3. Indicate the reason for the referral, such as suspected substance abuse, mental health concerns, or both.
4. Verify the individual's insurance information, including coverage details and policy number if applicable.
5. Include any relevant medical history or behavioral health treatment information that may assist in the assessment and referral process.
6. Use specific assessment tools or screening questionnaires, as required by the form, to gather additional information about the individual's substance abuse and behavioral health needs.
7. Document any observed symptoms or behaviors that support the referral, such as changes in mood, sleep patterns, or social functioning.
8. Specify any requested services or treatments, such as counseling, medication management, or residential treatment, that are recommended for the individual.
9. Sign and date the referral form, ensuring that contact information for the referring healthcare professional is provided.
10. Submit the completed referral form to the appropriate agency or treatment provider, following any specific instructions provided on the form or by the referring organization.

Who needs dmhdaodas sbirt referral form?

1. Healthcare professionals, including doctors, nurses, or counselors, who are conducting screenings for substance abuse and behavioral health disorders.
2. Organizations or agencies that provide substance abuse and behavioral health services and require a referral for intake or assessment purposes.
3. Individuals who suspect they may have substance abuse or behavioral health concerns and seek formal assessment and treatment services from qualified professionals.

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