TACT Target Population Youth Must Meet the Following Criteria? (Please check all that apply.)

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1 Transitional Age Community Treatment Team (TACT) Referral Form (Please Print or Type Referral Information) The TACT Team is designed for youth 16 to 24 years of age in need of assistance transitioning from out of home placements such as correctional or residential treatment facilities in need of intensive support to remain in the community due to severe persistent behaviors through a multidisciplinary approach. TACT Target Population Youth Must Meet the Following Criteria? (Please check all that apply.) Age 16 to 24 Absence of diagnoses in which active psychotic symptoms are present such as Schizophrenia or Schizo-Affective Disorder Accompanied by one or more of the following: History of out of home placements or residing in an inpatient supervised community residence but clinically assessed to transition to the community Demonstrates severe and persistent behaviors that interfere with transitioning from an out of home placement or remaining in the community Socially disruptive behaviors leading to deeper court involvement (e.g. arrest, incarceration) Co-existing substance abuse disorder of significant duration (6 months or more) Demonstrates severe and persistent behavioral challenges not directly attributable to Bi-Polar Disorder, Schizophrenia, Depression Recurrent, or Schizo- Affective Disorder Extreme difficulty participating in office appointments or traditional outpatient interventions due to severe and persistent behaviors A Collaboration between Recovery Resources & the ADAMHS Board 1/29/14 1

2 Date: Referral Source ( parent, CCDCFS, Self): Telephone Number: Name & Title of Referent: Address: Client Information Client s Name: Date of Birth: Gender: ( )Male ( ) Female pregnant Y( ) N ( ) Home Address: Social Security No.: Race: Primary Language: Telephone Number: Parent/Guardian Name: Last Grade Completed: Parent/Guardian Address: Parent/Guardian Phone: Emergency Contact Name: Name of School: Insurance Provider: Client History Current Diagnosis (past 12 months) including Dx Codes: Axis I: Axis II: Axis III: Axis IV: Axis V: (GAF) Emergency Contact Phone: Is client currently taking any OTC medications? Y ( ) N ( ) Please describe: Is client prescribed any medications due to mental health issues? Y ( ) N ( ) Please describe: Is client currently experiencing any suicidal/homicidal ideation? Y ( ) N ( ) If yes, please describe: Has client been tested for HIV? Y ( ) N ( ) Please indicate client s last drug and/or alcohol usage and when this occurred: Please indicate client s drug(s) or choice: Systems Currently Involved or pending involvement: ( )Juvenile Court ( )CCDCFS ( ) CCBDD ( ) Adult Court A Collaboration between Recovery Resources & the ADAMHS Board 1/29/14 2 ( ) ODYS

3 PLEASE INDICATE OFFENSE, SENTENCE, AND SUPERVISION STATUS IF APPLICABLE: Clinical Services Provided within the Past 12 months w/ dates (i.e. Counseling, CPST, Groups): History Of Out of Home Placements (if applicable)including dates: Supportive Documentation Please provide the following documents for determination: Mental Health Assessment Alcohol and Drug Assessment Psychological Reports Documentation of Prior Treatment Interventions (residential reports, outpatient services such as anger management, etc.) Any additional documentation A Collaboration between Recovery Resources & the ADAMHS Board 1/29/14 3

4 Rationale for Referral to TACT Team Please provide brief comments: For Office Use Only Please forward referrals to: Recovery Resources TACT Program Fax: (216) Phone: (216) Chester Ave. Cleveland, OH Date Reviewed: Date Reviewed: Referral Disposition: Once the referral is reviewed, Recovery Resources will contact the referent regarding the outcome of the referral. A Collaboration between Recovery Resources & the ADAMHS Board 1/29/14 4

5 AUTHORIZATION TO DISCLOSE INFORMATION Name of Client: Date of Birth: Recovery Resources Address: 3950 Chester Ave., Cleveland OH is authorized to: ( ) disclose ( ) receive ( ) exchange information with the entity named below: Individual Name: Organization Name: Street Address: City/State/Zip: Phone/Fax #: Purpose of Disclosure: ( ) to coordinate treatment, ( ) to gather assessment information for treatment planning, ( ) to gather information for ongoing treatment, ( ) other purposes [specify]: ( ) If re-releasing data from another agency, specify which info is to be released at this time only Client initials Type of Information to be Disclosed: ( ) progress notes, ( ) Assessment information, ( ) progress in treatment, ( ) lab results, ( ) attendance, ( ) HIV/AIDS testing or status, ( ) diagnosis, ( ) information on mental illness and/ or treatment, ( ) Termination Summary, ( ) other information specify]: Amount of Information to be Disclosed: ( ) information covering the previous three months, ( ) information covering the most recent admission, ( ) other amount of information [specify]: Client Signature & Date Staff/Witness Signature & Date Parent/Guardian Signature & Date Indicate expiration date : (Not to exceed 6 mos.) Please provide the client with a completed copy of this form REVOCATION: This authorization is subject to revocation at any time except to the extent the program or person who is to make the disclosure has already acted in reliance on it. Persons receiving drug/alcohol services can revoke this consent in writing. This authorization was revoked on this date: This authorization was revoked at this time: Client Signature &Date Witness Signature & Date Prohibition against Re-Disclosure: This information has been disclosed to you from records protected by Federal confidentiality rules. The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. (These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.) A Collaboration between Recovery Resources & the ADAMHS Board 1/29/14 5