Get Pa Magellan Behavioral Health Initial Referral For Family-based Services 2014-2025

This guide provides a comprehensive overview of how to complete the PA Magellan Behavioral Health Initial Referral For Family-Based Services form online. Whether you are a first-time user or have experience with similar forms, this step-by-step guidance aims to help you navigate the process effectively.

Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to access the form and open it in your chosen digital editor.
2. Begin by entering the date of referral in the designated field. This helps track when the request was initiated.
3. Fill in the referring agency provider number and name, along with the contact phone number and fax number of the referring agency for easy communication.
4. Identify and recommend a Family-Based Services provider, if applicable, and include a rationale for this choice to guide the referral process.
5. Ensure that consent has been obtained from the parent, guardian, or member over age 14 by marking ‘Yes’ or ‘No’ in the respective field. Include the date consent was received.
6. Complete the member’s personal details, including their name, date of birth, medical assistance identification number, current age, and gender.
7. Provide information about the member's school name and home school district, as well as details about their caregivers and legal guardians.
8. Detail optional demographic information, such as the race of the member, and include the home address, city, ZIP code, and phone number.
9. List siblings or others living within or out of the home, including their names and ages.
10. Document any other agencies currently involved with the member, providing names, ages, relationships, and contact information.
11. Specify the DSM-5 diagnosis if available, along with a brief history of the member’s social service agency involvement and mental health treatment history.
12. List any medications the member is taking, along with dosages and the prescribing physician’s contact information.
13. Indicate if the member is compliant with their medications by selecting ‘Yes’ or ‘No’ and providing an explanation if necessary.
14. Assess and report any behavioral or symptom factors that may indicate the level of risk for self-harm, marking the applicable checkboxes.
15. Check relevant psychosocial stressors affecting the member, noting both acute and enduring circumstances.
16. Evaluate the current potential for out-of-home placement, checking the applicable options that describe the member's situation.
17. Complete the referral section with your details as the person completing the form, including your title and the date of completion.
18. Once all fields are filled out, review the information for accuracy, then save your changes. You can choose to download, print, or share the completed form as required.

Begin filling out the PA Magellan Behavioral Health Initial Referral For Family-Based Services online now.