Youth Enhanced Care Management Provider Referral Form
For referrals to Enhanced Care Management Services (ECM), provider or staff should complete this referral form.
Date
-
Month
-
Day
Year
Date
Referring Provider and Practice Name
*
Referring Provider’s Phone Number
*
Please enter a valid phone number.
Referring Provider’s Fax Number
*
Please enter a valid fax number.
Referring Provider Email Address
*
example@example.com
Are you an Alliance-contracted ECM provider?
*
Yes
No
Member's Name
*
First Name
Last Name
Other names the member has used
First Name
Last Name
Member’s Date of Birth
*
-
Month
-
Day
Year
Date (Month-Day-Year)
Member ID
*
Note: If the member is not an active Alliance member, they do not qualify for this service.
Member’s Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member’s Phone Number
Please enter a valid phone number.
Has the patient/member been informed that an ECM referral is being requested?
*
Yes
No
Has the patient/member indicated a preferred ECM Provider?
*
Yes
No
Please confirm the preferred ECM Provider name
What is the primary problem/reason for the referral? (Please check all that apply)
*
Experiencing homelessness
Serious mental illness (SMI) or substance use disorder (SUD)
At risk for avoidable ED use or hospitalization
Enrolled in California Children’s Services (CCS) or CCS Whole Child Model
Involved in child welfare
Pregnant or it has been 12 months since the member delivered a baby
Intellectual or developmental disability
Transitioning from Incarceration
Does the member identify as Black/African-American?
Yes
No
Does the member identify as American Indian or Alaska Native?
Yes
No
Does the member identify as Pacific Islander?
Yes
No
As defined by DHCS for ECM/Community Supports, homelessness includes members who are in one of the following categories (please check the box that most closely aligns with member’s status)
Lacks adequate nighttime residence
Primary residence that is a public or private place not designed for or ordinarily used for habitation
Living in a shelter
Exiting an institution to homelessness
Will imminently lose housing in next 30 days
Unaccompanied youth and homeless families and children and youth defined as homeless under other federal statutes
Victims fleeing domestic violence
Sharing the housing of other persons (i.e., couch surfing) due to loss of housing
Does the member meet the criteria for participation in?: The County Specialty Mental Health (SMH) System
Yes
No
The Drug Medi-Cal Organized Delivery System (DMC-ODS)
Yes
No
Has the member had three or more emergency room visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence?
Yes
No
Has the member had two or more unplanned hospital and/or short-term skilled nursing facility stays in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence?
Yes
No
Is the member experiencing any of the following? (Select all that apply.)
Lack of access to food
Unstable housing or homelessness
Difficulty obtaining transportation
Contact with law enforcement
Lives alone
Has a high measure of ACEs screening (four or more)
Other social situation not listed above
Please describe other social situation not listed above
Is the member under age 21 and are currently receiving foster care in California?
Yes
No
Is the member under age 21 and previously received foster care in California or another state within the last 12 months?
Yes
No
Has the member aged out of foster care up to age 26 (having been in foster care on 18th birthday or later) in California or another state?
Yes
No
Is the member under age 18 and eligible for and/or in California’s Adoption Assistance Program?
Yes
No
Is the member under age 18 and currently receiving or has received services from California’s Family Maintenance program within the last 12 months?
Yes
No
Has the member recently been released from a correctional facility (prison or jail) or transitioned from correctional facility within the past 12 months?
Yes
No
Additional Comments
Submit Form
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