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Get the free Adult Behavioral Health Home & Community Based Services and Core Referral Form

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This document serves as a referral form for individuals seeking Adult Behavioral Health Home and Community Based Services (HCBS) and CORE services. It includes sections for entering participant information, health care details, diagnoses, and agency contact information, as well as specific services required.
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How to fill out adult behavioral health home

01
Gather necessary personal information including name, age, and contact details.
02
Provide information about your mental health history, including any previous diagnoses or treatments.
03
List all medications you are currently taking, along with dosage and prescribing physician.
04
Fill out emergency contact information, detailing who to reach out to in case of an emergency.
05
Answer questions regarding current symptoms, stress factors, and daily functioning.
06
Attach any required documentation, such as proof of insurance or referrals from healthcare providers.
07
Review the form for completeness and accuracy before submitting it.

Who needs adult behavioral health home?

01
Adults experiencing mental health challenges that require support and supervision.
02
Individuals who have a history of behavioral health issues and need a structured environment.
03
Those transitioning from hospitalization to a stable living environment.
04
Individuals seeking a community setting that promotes recovery and social interaction.
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An adult behavioral health home is a model of care designed to provide comprehensive and coordinated behavioral health services to adults with mental health and substance use disorders, focusing on holistic support and community integration.
Providers and organizations that operate adult behavioral health homes and seek reimbursement or certification from relevant health authorities are required to file adult behavioral health home.
To fill out an adult behavioral health home, you will need to complete the designated forms provided by the state's health department, ensuring that all required information about the services, staff qualifications, and patient care plans are accurately documented.
The purpose of adult behavioral health home is to provide integrated, patient-centered care that improves access to services, enhances the quality of care, and supports recovery by addressing both behavioral and physical health needs.
Information that must be reported includes details about the facility, staff qualifications, service offerings, patient demographics, outcomes of care, and adherence to treatment plans.
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