Get Pa Magellan Behavioral Health Initial Referral For Family-based Services 2018-2025

This guide provides a comprehensive overview and step-by-step instructions for filling out the PA Magellan Behavioral Health Initial Referral for Family-Based Services form online. By following these clear directions, users can ensure that they complete the form accurately and efficiently.

Follow the steps to complete your referral form online.

1. Press the ‘Get Form’ button to obtain the referral form and open it in your document editor.
2. Begin by entering the date of referral in the designated field along with the referring agency provider number, staff name, and phone number. Ensure all agency contact information is accurate.
3. Provide the name of the recommended Family-Based Services provider and the rationale for the referral if applicable. This may include clinical reasons or specific references.
4. Verify that the parent, guardian, or member over the age of 14 has given consent for the release of information. Mark 'Yes' or 'No' and include the date consent was received.
5. Fill in the member's personal details including their name, MA ID number, date of birth, current age, and optionally their race. Add the name of the school and home school district.
6. List caregiver(s) and legal guardian(s), including their relationship to the member. Ensure you include all relevant individuals involved in the member's care.
7. Complete the home address section by providing the full address, city, and ZIP code. Include a contact phone number.
8. Document any siblings or others living in or out of the home. Include their names, ages, and relationships to the member.
9. If applicable, include other agencies involved in the member's care, along with their contact information and phone numbers.
10. Detail any DSM-5 diagnoses and document relevant mental health treatment history, including outpatient and inpatient services, with dates.
11. List any medications the member is currently taking, their dosages, and the prescribing physician's contact information.
12. Assess and indicate the member's compliance with medications and provide an explanation.
13. Evaluate risk factors related to behavior or symptoms for self-harm and check applicable items in the provided categories.
14. Discuss the current or potential risk for out-of-home placement and select the appropriate option based on the member's situation.
15. Complete the referral by filling out the referral completed section, including the name and title of the person completing the form.
16. Once completed, review all entries for accuracy, then save your changes, download, print, or share the form as needed.

Start completing your PA Magellan Behavioral Health Initial Referral for Family-Based Services form online today!