Get San Diego County Hhsa & Mental Health Provider

This guide provides step-by-step instructions for completing the San Diego County HHSA & Mental Health Provider form. It is designed to support users in properly filling out the form to ensure an effective referral process.

Follow the steps to effectively complete the referral form.

1. Click ‘Get Form’ button to access the referral form and open it in the designated editor.
2. Begin by entering the 'date of referral' in the specified format (MM/DD/YYYY). Fill in your name as the person making the referral, and provide your email address if available. Next, fill in the referring agency information and your contact phone number, followed by your address and fax number.
3. In the identifying information section for the person being referred, input their full name, last four digits of their social security number, aliases, address, and phone number. Include their date of birth and preferred language. Additionally, indicate whether they have experienced homelessness with a prompt to note the period of homelessness.
4. Complete the clinical information section by specifying if the person is interested in case management. If applicable, provide specific reasons for the referral, current barriers or challenges, and detail their mental health stage of recovery.
5. Document the person's mental health treatment history, including the number of psychiatric hospitalizations in the last two years and if there is any problematic substance use. Record the date of last use and the substance of choice.
6. In the diagnoses section, fill out all relevant axes, including Axis I for primary and secondary diagnoses, Axis II, III, IV, and V, detailing the individual's support system and socio-economic status.
7. Enter current medical issues by providing the name and phone number of the primary care physician and current treating psychiatrist, if applicable.
8. For legal information, note if the person has a conservator, been incarcerated, or is currently on parole or probation. Provide any pertinent legal information.
9. Fill out financial and insurance details, including income sources and insurance status. Provide Medi-Cal number or any other relevant insurance information.
10. Once all sections are complete, review for accuracy and clarity, then sign the form as the person completing the referral and enter the date.
11. Finally, save your changes, download, print, or share the completed form as needed.

Complete your San Diego County HHSA & Mental Health Provider referral form online today.