2. Carlton Country ACT Referral and Screening Tool

4. Client Name:*
5. Phone Number:*
7. Date of Birth:*
8. Email:*
10. Address:*
11. Length of time at current address:*
13. Date of Referral:*
14. Referral Source:*
16. Referring Phone Number:*
17. Role/Relationship to client:*
19. Referral notes to pass along for this client:
21. Race/Ethnicity:*

    1. American Indian (list tribe below)
    2. Asian (list ethnicity below)
    3. Black/African American
    4. Caucasian
    5. Pacific Islander
    6. Unable to determine
23. Tribe or Ethnicity:
25. Insurance:
27. GA/MA #:
28. PMI #:
29. Medicare #:
31. Private Insurance:
33. Current Service Providers: (List Name and Agency)
35. Therapist Name / Agency:
36. ARMHS Name / Agency:
38. Probation Name / Agency:
39. Primary MD/Clinic Name / Agency:
41. Dentist Name / Agency:
42. Psychiatrist Name / Agency:
44. Guardian/Conservator Name / Agency:
45. Rep Payee Name / Agency:
49. Voluntarily wants ACT service:*

    1. Yes

    1. No
50. Was ACT referral discussed with Psychiatrist?*

    1. Yes

    1. No
52. Pertinent Comments from Psychiatrist:
54. Does the potential Client have a legal guardian/conservator?*

    1. Yes

    1. No
56. Current sources of Employment:

    1. SSI
    2. SSDI/RSDI
    3. MFIP

    1. Employment
    2. Tribal Enrollment
57. Other:

    (please list)

59. Is the potential client currently committed?*

    1. Yes

    1. No
61. Commitment Type:

    1. MI
    2. MI/CD

    1. CD
    2. MI&D
62. Other:

    (Specify)

64. Order Expiration Date:
66. Other Orders:

    1. JARVIS

    1. Price Sheppard
67. Other:

    (Specify)

69. Placement (i.e. IRTS/CBHH)

    1. Yes
    2. No
70. Location:
71. Discharge Date:
75. Disability Diagnosis:

    1. Chemical Dependency (alcohol/drugs, etc.)
    2. Fetal Alcohol Syndrome (FAS)
    3. HIV/AIDS
    4. Traumatic Brain Injury (TBI)

    1. Developmental Disability
    2. Hearing Impairment
    3. Visual Impairment
76. Other:

    (Specify)

78. Eligibility for ACT:*

    1. Age 18 or older
    2. Age 16-17 with a variance
80. Has a primary Diagnosis:

    1. Schizophrenia
    2. Schizoaffective Disorder

    1. Bipolar Disorder
    2. Major Depressive Disorder w/ psychotic features
81. Other:

    (Specify)

85. Has significant functional impairments as demonstrated by at least one of the following conditions:*

    1. Significant difficulty consistently performing the range of routine tasks required for basic adult functioning in the community or persistent difficulty performing daily living tasks without significant support or assistance.
    2. Significant difficulty maintaining employment at a self-sustaining level or significant difficulty consistently carrying out the head-of-household responsibilities, or
    3. Significant difficulty maintaining a safe living situation.
87. Has a need for continuous high-intensity services as evidenced by at least two of the following:*

    1. Two or more psychiatric hospitalizations or residential crisis stabilization services in the previous 12 months.
    2. Frequent utilization of mental health crisis services in the previous six months.
    3. 30 or more consecutive days of psychiatric hospitalization in the previous 24 months.
    4. Intractable, persistent, or prolonged severed psychiatric symptoms.
    5. Coexisting mental health and substance use disorders lasting at least six months.
    6. Recent history or involvement with the criminal justice system or demonstrated risk of future involvement.
    7. Significant difficulty meeting basic survival needs.
    8. Residing in substandard housing, experiencing homelessness, or facing imminent risk of homelessness.
    9. Significant impairment with social and interpersonal functioning such that basic needs are in jeopardy.
    10. Coexisting mental health and physical health disorders lasting at least six months.
    11. Residing in an inpatient or supervised community residence but clinically assessed to be able to live in a more independent living situation if intensive services are provided.
    12. Requiring a residential placement if more intensive services are not available.
    13. Difficulty effectively using traditional office-based outpatient services.
    14. There are no indications that other available community-based services would be equally or more effective as evidenced by consistent and extensive efforts to treat the individual.
    15. In the written opinion of a licensed mental health professional, has the need for mental health services that cannot be met with other available community-based services, or is likely to experience a mental health crisis or require a more restrictive setting if assertive community treatment is not provided.
89. Please provide more information for any of the above answers*

    (i.e. Where, dates, and specific examples)

93. Other Information:

    Is or does the potential client have:

    1. Substance-related treatment?
    2. Competitive employment?
    3. Waiver Services?
    4. A completed LOCUS?
    5. The person voices an intent to form a working relationship with the ACT team and to adhere to agreed-upon treatment recommendations.
95. Please provide more information for any of the checked items above.

    (i.e. Specify where & when, Waiver case Manager, most recent LOCUS Score.)

99. Please Attach/Email/Mail (to contacts below) any complete releases of information, as applicable, for all past and current psychiatric and /or chemical dependency of the following:

    1. Hospitalizations (e.g. private, CBHH, ER)
    2. Crisis facilities
    3. Residential settings (e.g. IRTS, halfway house, adult foster care)
    4. Partial hospitalization programming
    5. Outpatient (e.g. therapy, psychiatric, neuropsych)
    6. Community-based services (e.g. ARMHS, ICRS)
    7. Legal (e.g. civil commitment, guardian, prison, probation officer)
    8. Medical (e.g. primary care physician)
    9. County (e.g. Case manager, financial worker)
    10. Attach medication list
    11. Attach most current Diagnostic Assessment
101. Attach supporting documentation:
103. Attach supporting documentation:
105. Attach supporting documentation:
107. Please use either of the contacts below to provide further information:
109. Angela Hartwig, ACT Team Supervisor

     Carlton County Public Health & Human Services

     14 N. 11th St, Suite 200, P.O. Box 660

     Cloquet, MN 55720

     Phone: 218-428-3574

     Fax: 218-879-1160

     Email: angie.hartwig@carltoncountymn.gov

110. Molly Hastings, ACT Program Assistant

     Carlton County Public Health & Human Services

     14 N. 11th St, Suite 200, P.O. Box 660

     Cloquet, MN 55720

     Phone: 218-626-7902

     Fax: 218-879-1160

     Email: molly.hastings@carltoncountymn.gov

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112. 1. Receive an email copy of this form.
113. Email address

     This field is not part of the form submission.

114. Submit

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