CPS Referral Form

Referral for Certified Peer Specialist Services

CenClear
50 Bigler Rd
Woodland, PA 16881
Phone: (814) 342-5845 or 1-877-341-5845
Fax: (814) 342-2900
Certified Peer Specialist Referral Form – BH 94
This referral form is for persons aged 14+
 

Note: Please fax completed referral form with written recommendation for PSS and accompanying signature of LPHA to the above fax number.

Name*:
Birth Date*:
Date*:
Preferred Name:
Preferred Pronoun:
Address*:
Medical Assistance*:
MA Number:
Veteran Status*:
Home Phone*:
Cell Phone:
Referral Source:
Referral Name:
Referral Address:
Referral Phone:
Please list any Services or Agencies that the consumer is currently involved with (mental health or substance use disorder):
Adult Criteria for Eligibility (must meet one)
Met standards for involuntary treatment in the past 12 months preceding this assessment:
Currently resides in State Mental Hospital or discharged from State Mental Hospital in the past 2 years:
2 admissions to inpatient psychiatric unit or crisis residential totaling 20 or more days in the past 2 years:
5 or more face to face contacts with walk-in, mobile, or emergency services within the past 2 years:
1 or more years of continuous attendance in a community mental health or prison psychiatric service within the past 2 years:
History of sporadic course of treatment, inability to maintain med regime, or involuntary commitment to outpatient services:
1 or more years of mental health treatment provided by a PCP within the past 2 years:
Release from criminal detention:
Homelessness:
Co-existing Diagnosis or Disability:
Other:
Youth and Young Adult Criteria for Eligibility: History of Serious Emotional Disturbance (SED):
Dates:
********* Following to be completed by LPHA (Licensed Practitioner of the Healing Arts) ********
Qualifying LPHAs are limited to: physicians, physician assistants, certified registered nurse practitioners, psychologists, licensed clinical social workers, licensed professional counselors, and licensed marriage and family therapists.
DSM 5 Problem List (Serious Mental Health or Emotional Disturbance):
Identify current needs/potential goal areas:
Wellness Recovery/Action Planning:
Advanced Directive:
Use of community resources:
Vocational:
Educational:
Treatment options:
Increased support network:
Self Maintenance:
Transportation Resources:
Social/Relationship Skills:
Housing:
Written recommendation for PSS (Peer Support Services): [Please identify the functional impairment that the referred individual experiences as a result of the previously documented SMI/SED.] *:
I recommend that it is medically necessary for
Full Name:
to receive Certified Peer Specialist services and they agree to participate in these services.
Printed Name of Physician/Psychologist/PA/CRNP/LCSW/LPC:
NPI #: