Get How To Fill Out A Uniform Screening And Referral Form

Filling out the Uniform Screening and Referral Form online can be a straightforward process. This guide provides clear instructions to help you complete each section accurately, ensuring all necessary information is collected for effective screening and referral.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the uniform screening and referral form and open it in your preferred online editor.
2. Begin by entering your agency name and the date of prescreening in the designated fields. Additionally, provide the screening location, phone number, and the start and end times of the screening.
3. In the section regarding consultation with the home agency, indicate whether you have notified them if screening an individual from another area. If not, ensure to notify them within 24 hours.
4. Fill out the Identifying Information section, including the individual's first name, last name, MI, address, city, state, telephone, and county. Also, select their preferred language, date of birth, sex, marital status, and ethnic group.
5. Provide the social security number and fill out the information for the family/contact person, including their relationship, address, and telephone number. If the individual has a guardian, fill out their details in the corresponding fields.
6. Answer the question regarding dependents in the individual's care. If applicable, describe the number, age, and gender of dependents along with care arrangements.
7. Indicate if the individual has received non-crisis services from an Illinois state-funded community mental health center in the last 6 months, and provide financial information by checking all relevant income sources and medical coverage.
8. In the Presenting Problem section, detail the individual's chief complaint, history, perceived problems, current stressors, and issues needing acute care. Include any relevant abuse treatment needs.
9. Summarize mental health history, substance use, and dependencies, including frequency and last use, ensuring to note any risk factors related to detox or psychiatric concerns.
10. Review medical status, allergies, and medications. It may be beneficial to attach a complete listing of medications as specified.
11. Assess personal history and current status, including social, vocational, and self-care functioning, as well as legal history if necessary.
12. Complete the Mental Status section by checking appropriate findings and providing details where required.
13. Conclude with observations regarding the level of violence risk and indicate the diagnostic conclusions based on the assessment.
14. For referral details, fill out the provider to which the individual will be referred, including name, address, and contact information.
15. Finally, provide your signature, printed name, and date to confirm the evaluation of the individual's mental health treatment needs.
16. Once all sections are filled out, save your changes, and download, print, or share the form as needed.

Complete your uniform screening and referral forms online for a more efficient process.