LIFENET
MOBILE CRISIS REFERRAL
CENTRAL
PROVIDER FASTRACK REFERRAL FORM
* CALL 911 IF CLIENT IS ACTIVELY SUICIDAL OR HOMICIDAL OR AT
IMMINENT RISK, REQUIRING IMMEDIATE
POLICE / EMS RESPONSE
** After 4:30PM Mon – Fri and Weekends, you MUST call 1-800-LifeNet
to make an MCT Referral.
Only fax referrals Mon – Fri 9:00AM – 4:30PM
Today’s date:
Click on dropdown box to choose date.
SUBMIT EACH REFERRAL
SEPARATELY
☐
New Referral
☐
Re-Submit
FAX TO: 866-314-7707
CLIENT INFORMATION
Client’s Name:
Last:
First:
Middle:
Parent or Guardian Name and
Name:
Phone # (if a minor)
Click here to enter text.
Click here to enter text.
Date of Birth:
Age:
Sex:
Click here to enter
Click here to enter
☐ M
☐F
text.
text.
Street Address:
Click here to enter text.
City:
Click here to enter text.
State:
NY
Phone #:
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Language:
Click here to enter
text.
Apartment #:
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text.
Zip Code:
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text.
Primary Contact Name:
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Marital Status:
Click here to enter
text.
Phone #:
Click here to enter
text.
Alternate Phone #:
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text.
Phone #:
Click here to enter
text.
REFERRAL SOURCE INFORMATION
ANONYMOUS REFERRALS ARE NOT ACCEPTED
YOU OR DESIGNATED PARTY MUST BE AVAILABLE WITHIN ONE HOUR OF FAX TRANSMISSION TO ANSWER ANY QUESTIONS
Referral Source’s Name: Click here to enter text.
Relationship: Click here to enter text.
Phone #: Click here to enter text.
Email Address:
Click here to enter text.
Name of Referring Facility or School
1
Click here to enter text.
Address
Click here to enter text.
Is Referral Source available for call back within 1 hour from time of fax
transmission?
☐ Yes
☐ No
Name of person available within the hour for call back:
Person’s name:
Phone #:
Relationship:
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Click here to enter text.
Click here to enter text.
Supervisor’s Name:
Phone #:
Department:
Click here to enter text.
Click here to enter text.
Click here to enter text.
Has client used MCT services in the past?
☐ Yes
☐ No
☐ Unknown
Can referral source or another person assist team to
☐ Yes
☐ No
☐ Unknown
gain access to client?
Name and contact number of other person who can
Click here to enter text.
assist team.
MINORS ONLY – Parent is aware referral is being
☐ Yes
☐ No
☐ Unknown
made?
SCHOOL REFERRALS ONLY – Parental consent
☐ Yes
☐ No
☐ Unknown
obtained for school visit?
REFERRALS FROM BEHAVIORAL HEALTH OR
Date:
Time:
ALCOHOL AND/OR SUBSTANCE USE DISORDER
Click on dropdown box to choose Click here to
PROVIDERS require an Outpatient Appointment date date.
enter text.
within 3 to 5 business days when the client can
return back to your clinic or program.
PLEASE PROVIDE SPECIFIC APPOINTMENT:
Behavioral Health or Alcohol and/or Substance Use Click here to enter text.
Disorder clinic name:
Therapist Name: Click here to enter text.
Phone #: Click here to enter text.
New to clinic?
☐ Yes
☐ No
☐ Unknown
Length of time enrolled in clinic: Click here to enter text.
Date last seen by Behavioral Health or Alcohol
and/or Substance Use Disorder Provider:
Last date of other contact with Behavioral Health or
Alcohol and/or Substance Use Disorder Provider:
Have attempts been made to contact client?
Is client connected to treatment?
Is client attending treatment?
Is client willing to return to treatment?
Describe barriers if client is unwilling to return to
treatment:
Behavioral Health Diagnosis:
Click on dropdown box to choose date.
Click on dropdown box to choose date.
☐
☐
☐
☐
Yes
Yes
Yes
Yes
☐
☐
☐
☐
No
No
No
No
☐
☐
☐
☐
Unknown
Unknown
Unknown
Unknown
☐ No
☐
Unknown
Click here to enter text.
Axis I
Axis II
Click here to enter text.
Substance Use Disorder Diagnosis:
Client is known to or suspected of actively using
substances at this time?
☐ Yes
2
Name of substances?
Psychiatric Hospitalization in past twelve months?
If yes, date most recent:
Total Number of Psychiatric Hospitalizations (in
past twelve month period): Click here to enter text.
Click here to enter text.
☐ Yes
☐ No
☐ Unknown
Click on dropdown box to choose date.
Check all that apply for hospitalizations in the past
12 month period:
☐ 0-3 months ☐ 3-6 months ☐ 6-12 months
Name of APS Worker:
Click here to enter text.
Phone #: Click here to enter text.
Are there weapons in the home?
☐ Yes
☐
Are there dogs in the home?
☐ Yes
☐
Any information needed to access the home? (i.e.
Click here to enter text.
bell not working, use side entrance)
No
No
☐ Unknown
☐ Unknown
REASON FOR REFERRAL
In each box: PLEASE PROVIDE SPECIFIC EXAMPLES AND INCLUDE TIME FRAME. INCLUDE A MINIMUM OF 4 SENTENCES
FOR CLARIFICATION.
REQUIRED
NARRATIVE
REQUIRED
NARRATIVE
REQUIRED
NARRATIVE
REQUIRED
NARRATIVE
REQUIRED
NARRATIVE
What is currently
putting client at risk?
Has there been a
change in client’s
behavior or
functioning in the last
3 days?
Incident or concern
that prompted you to
make the MCT referral
today?
What makes client
unable or unwilling to
seek services at this
time?
Describe any suicidal
and/or homicidal
ideation, plan or
intent client has
expressed in last 2
months. Please
include dates.
PHYSICAL DESCRIPTION
REQUIRED NARRATIVE
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REQUIRED NARRATIVE
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REQUIRED NARRATIVE :
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REQUIRED NARRATIVE (IF NONE PLEASE STATE ”NONE”)
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REQUIRED NARRATIVE – PHYSICAL DESCRIPTION OF CLIENT (INCLUDE
ETHNICITY)
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3
OTHER
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IMPORTANT
INFORMATION
(INCLUDE ANY
SIGNIFICANT
LEGAL
INVOLVEMENT
Current Presenting Concerns in the
Last Two Months Relevant to the
Referral:
Any notable impairments in
performing daily activities?
Select all that apply
Suicidal Ideation
☐ Stress
☐
Developmental Delay
☐ Anxiety
☐
Cognitive Impairment
☐ Hallucinations -------Affective Liability
Visual
☐
☐
Depressiveness
Auditory
☐
☐
Tactile
☐
Interpersonal Violence --Olfactory
☐
Domestic Violence
☐ Delusions
☐
Sexual Assault
☐ Paranoia
☐
Stalking/Harassment ☐ Flashbacks
☐
Homicidal Ideation
☐ Substance Use / Abuse
☐
☐ Recent Missed
☐
Poor Reality Testing
Appointments
Violent or Destructive
Click on
☐
List last 3
Behavior within the last 3
dropdown box
missed
days
to choose
appointments:
date.
Click on
Click on
Other (describe):
dropdown box dropdown box
☐
Click here to enter text.
to choose
to choose
date.
date.
Select all that apply
Sleep
Appetite
☐
☐
Personal Hygiene
Concentration
☐
☐
Memory
Leaving Home
☐
☐
Enjoying Activities
Maintaining Home
☐
☐
Other (describe):
Attending School
Click here to enter
☐
☐
text.
☐
Working
Suicidality or Potential for Self-Harm
Is client having thoughts today about
suicide?
Yes
☐
No
☐
Unknown
☐
Has client thought about suicide in the
last two months?
Yes
☐
No
☐
Unknown
☐
No
Unknown
Yes
4
Has client ever attempted to kill
☐
☐
themselves?
In the last two months, has client ever
Yes
No
attempted to hurt themselves, by
☐
☐
cutting, pinching skin, banging head,
picking scabs, etc.
If answer to any of the above questions is YES, then complete the following:
(If NO, then skip to Homicidality or potential for Harming Others Section)
Number of previous suicide attempts: Click here to enter text.
Date 1: Click on dropdown box to Date 2: Click on dropdown box to
choose date.
choose date.
Method of previous suicide attempts: Click here to enter text.
Does client have a plan to kill themselves?
Describe: Click here to enter text.
Does client have the means (pills, gun etc…) to kill
themselves?
Describe: Click here to enter text.
Has client expressed intent to kill themselves
(preparatory behaviors such as giving away treasured
possessions, writing a suicide note, learning about
methods to kill themselves, etc…?
Describe: Click here to enter text.
☐
Unknown
☐
Date 3: Click on dropdown box to
choose date.
☐ Yes
☐
No
☐ Unknown
☐ Yes
☐
No
☐ Unknown
☐ Yes
☐
No
☐ Unknown
Homicidality or Potential for Harming Others
Is client having thoughts today of
killing/harming someone else?
Yes
☐
No
☐
Unknown
☐
Has client thought about
killing/harming someone in the last
two months?
Yes
☐
No
☐
Unknown
☐
Has client ever physically harmed or
attempted to kill someone in the past?
Yes
☐
No
☐
Unknown
☐
If answer to any of the above questions is YES, then complete the following:
(If NO, then skip to Risk Factors for Suicide and Homicide Section)
Number of previous homicidal/violent acts: Click here to enter text.
Date 1: Click on dropdown box to Date 2: Click on dropdown box to
choose date.
choose date.
Method of previous homicidal acts: Click here to enter text.
Does client have a plan to hurt or kill someone else?
Describe: Click here to enter text.
☐ Yes
5
Date 3: Click on dropdown box to
choose date.
☐
No
☐ Unknown
Does client have the means (pills, gun etc…) to hurt
or kill someone else?
Describe: Click here to enter text.
☐ Yes
☐
No
☐ Unknown
Has client expressed intent to hurt or kill someone
else (preparatory behaviors, etc…?
Describe: Click here to enter text.
☐ Yes
☐
No
☐ Unknown
Select all that apply
Perceives self to
be a burden to
others
☐
Traumatic Brain
Injury (TBI)
☐
Substance Use
☐
Returning
Veteran
☐
Isolated/Lack of
Social Supports
☐
Unemployed
☐
Financial Issues
Divorce /
Separation
☐
Legal Problems
☐
Homeless/
Unstable
Housing
☐
Unknown
☐
Recent Loss ---
Risks Factors for Suicide/Homicide:
Job ☐
Family
☐
Member
Friend ☐
None reported
Active Psychiatric
Medication?
Active Non-Psychiatric
Medication?
Allergies to Medication
None
None
☐
☐
☐
☐
Drug Name
Click here to enter text.
Dosage
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
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Click

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Click

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Click
6
HEALTH INSURANCE INFORMATION
CLIENT CAN STILL RECEIVE SERVICES WITHOUT HEALTHCARE INSURANCE
Is client covered by insurance?
☐
Yes
☐
No
Insurance Carrier:
Click here to enter text.
Primary Insured:
Carrier’s Phone #:
Policy/Member ID:
Click here to enter text.
Click here to enter text.
Click here to enter text.
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