Get Ca Adult's Fsp Referral/authorization Form 2014-2025

Filling out the CA Adult's FSP Referral/Authorization Form online is an essential step in providing individuals with the necessary mental health services. This guide will walk you through each section of the form to ensure a complete and accurate submission.

Follow the steps to complete the form online.

1. Click the 'Get Form' button to access the form and open it for editing.
2. Begin by filling out the referral information section. Provide the DMH IS#, date, Social Security Number (SSN), last name, first name, date of birth (DOB), preferred language, race/ethnicity, age, and contact address of the individual. Ensure all details are accurate to avoid any delays.
3. Indicate the gender of the individual using the options provided: Male, Female, or Unknown.
4. Fill in the current living situation and provide a phone number for the individual.
5. Select the appropriate insurance information, ensuring to mark all applicable benefits such as Medi-Cal, Medicare, and others.
6. If applicable, provide details about any military service the individual has received.
7. In the primary contact section, fill in the name and phone number of the person to be contacted regarding this referral.
8. Complete the referral source details, including agency name, phone, contact person, and e-mail, and indicate whether the individual is currently receiving mental health services.
9. List any other agency involvement if applicable, including parole or probation details.
10. Select appropriate reasons for referral and indicate the focal population category, ensuring to check all that apply.
11. Provide details under the level of service section, ensuring to check only one box and provide any necessary information regarding past services.
12. Fill in the diagnostic considerations section, indicating any relevant diagnoses and providing detail for any checked items.
13. Once all fields are completed, review the form for accuracy and completeness before saving your changes. You can choose to download, print, or share the completed form as needed.

Complete the CA Adult's FSP Referral/Authorization Form online today to help individuals receive critical mental health services.