Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.CREDIBLE HEALTH SOLUTIONS Mental Health Targeted Case Management (MHTCM) Two-Phase Client Intake Packet Phone: 281-339-7665 | Email: Veidusuyi@CredibleHS.com Referral FormReferral Date: *Referred By (Name and Title): *Organization/Facility (if any):Phone Number: *Email *Relationship to Client *ParentGuardianSchoolAgencyOtherOther RelationshipReason for Referral *Presenting Problems: *AggressionTruancyEmotional ConcernsFamily ConflictPeer ConflictSubstance UseAcademic ProblemsHousing InstabilityOthersOther ProblemsProvisional Diagnosis (if known):Current Medications:Prescriber (if any):Family Mental Health History:Current Living Situation:With ParentsFoster CareShelterRelative’s HomeGroup HomeOtherOther Living SituationHow long at this address?Siblings (Names and Ages):2. Client and Family DemographicsClient Full Name: *Date of Birth: *Gender: *MaleFemaleOtherOther GenderRace/Ethnicity *Primary Language: *Social Security Number(optional)Medicaid ID No. *School Name: *Grade: *Legal Guardian Name: *Relationship to Client: *Phone Number: *Email *Client Insurance Name *Client Insurance Number *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact Name *Emergency Contact Phone *Relationship to Client *3. Consent for MHTCM ServicesI consent to receive Mental Health Targeted Case Management (MHTCM) services from Credible Health Solutions. Client/Guardian Name *Date *Staff Signature Automatic Date Form Date 4. Consent to Treat a Minor(If client is under 18 years of age) I give permission for my minor child to receive MHTCM services through Credible Health Solutions. Parent/Guardian Name *Date *5. HIPAA Acknowledgment *I acknowledge I received and reviewed Credible Health Solutions’ Notice of Privacy Practices.Date *6. Telehealth Consent Form *I consent to participate in telehealth services, including videoconferencing or phone sessions.Date7. Release of Information (ROI) *I authorize Credible Health Solutions to release/receive information to/from:Name of Provider/Agency: *Phone/Fax: *Purpose: *Coordination of CareEvaluationMedical HistoryOther:Other PurposeDate *Submit
