Behavioral Health

Behavioral Health Linkages Request

The purpose of this form is to start the process of behavioral health linkages for an incarcerated person. Referrals will be accepted from correctional facilities and CalAIM Jail Linkages Coordinators.

Requesting Entity Information

This section is for an agency requesting Behavioral Health linkage for an inmate in your jail system.

Requester Name First Name

Last Name

Requester Email example@example.com

What county are you requesting service from? Value is not selected

What kind of facility is the person currently in? Value is not selected

Phone number of facility or main contact Please enter a valid phone number.

Physical address of the person in the facility Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Behavioral Health

Client Information

Client Name First Name

Last Name

Client Medi-Cal #

Client Medi-Cal County of Insurance Value is not selected

Client Date of Birth Date

Client Email example@example.com

Phone number upon release Please enter a valid phone number.

Is the person on any medication?

Yes

What is the person's housing situation at release?

Living in a place not meant for human habitation (street/car/river/camp/etc.)

Shelter

Transitional Housing

Exiting to Other Institution

Not Homeless (Housed)

Client Address at Release Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Behavioral Health

Scheduling and Coordination

Facility entry date Date

Expected release date from the facility Date

Can your facility accommodate telehealth appointments?

Yes

What times of the day are best for contacting the client regarding linkages?

6am-10am

10am-2pm

2pm-6pm

6pm-10pm

Below are Placer County's Preferred Screening Tools

For adults with a suspected substance use need, please complete a BQuip and attach the result: BQuiP Document

The Adult Screening and Transition of Care Tools for Medi-Cal Mental Health Services ensures that Medi-Cal members are directed to the most approrate level of treatment (Managed Care Plan or County Mental Health Plan).

The Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services ensures that Medi-Cal members are directed to the most approrate level of treatment (Managed Care Plan or County Mental Health Plan). This is appropate for youth 20 years and younger.

If the referred individual is justice involved and was screened for Managed Care Plan (MCP), contact Partnership at bh-access@partnershiphp.org and upload the MCP document.

Referral Information

Universal Screening Tool for Level of Care Drag and drop files here

BQuiP Drag and drop files here

Medical Record Drag and drop files here

Release of Information Sharing of information is allowable under coordination of care without Release of Information. If ROI is available and signed, upload here.

By submitting this form, I agree this information is accurate and I am making the referral as an approved entity through CalAIM.

Yes

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ASOC BH

Behavioral Health