Fillable Mental Health Level of Care Screening Tool PCP (CalOptima)

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Mental Health Level of Care Screening Tool PCP (CalOptima)

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  • 26 check-boxes
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Referral Date: ____________
PCP Information
Mental Health Level of Care Screening Tool
Primary Care Provider: Health Network:
Address:
Member Information
City: ZIP: Phone: ( )
Member Name: Date of Birth: / / M F
Medi-Cal Number (CIN): Language: Phone: ( )
Mild to Moderate Impairment in the Following Areas of Functioning Due to a Mental Health Condition:
At risk of losing job, falls behind at work or school at times, or some difficulty caring for family and home
Has had some contact with the police or one or more arrests
Few friends, or has conflict or infrequent contact with friends
Occasional disagreement with family or strained relationships and/or infrequent contacts with family
Able to identify or engage in very limited acceptable/appropriate activities
Occasionally fails to maintain personal health and hygiene
May require some assistance from others at times to live independently or occasionally dependent on others for shelter, at risk of
becoming homeless
Thoughts about harming self or others on a few occasions or thought s/he might be better off dead
Some concerns the child may not be progressing developmentally as individually appropriate (21 and under)
Other:
Severe Impairment in the Following Areas of Functioning Due to a Mental Health Condition:
Not seeking employment, unable to keep job or stay in school, or failing school, or unable to care for family and home
Frequent problems with the law
Isolated, no friends, or avoids friends s/he has
Avoided by family, frequent conflict with family and/or neglects family
Unable to identify or engage in acceptable/appropriate activities
Fails to maintain personal health and hygiene
Dependent on others for shelter, homeless
Frequent thoughts of committing suicide and/or harming others
Recent psychiatric hospitalization
A reasonable probability the child is not progressing developmentally as individually appropriate (21 and under)
Other:
PCP Request
Referral for CalOptima Behavioral Health Services: Refer members with MILD to MODERATE level of functional impairment
for therapy or medication management when their needs are outside the PCP scope of practice, OR
Referral for Orange County Specialty Mental Health Services: Refer members with SEVERE level of functional impairment to
county mental health services.
Referral for Substance Use Disorder Services: refer members with substance use disorders and SBI referrals.
PCP Decision Support: Request a telephone consultation with a Beacon psychiatrist to provide decision support related to member
diagnostic and medication clarification or other clinical decision supports.
Motivation for Services (check all that apply)
Member (or guardian) has been informed of referral to Beacon Health Strategies
Member wants services for self (or dependent)
If applicable, member has completed a PHQ-2/PHQ-9. Score:
Updated 06/2015
Referral Date: ____________
Instructions for Referrals:
Referral for CalOptima Behavioral Health Services: Refer members with MILD to MODERATE level of functional impairment
for therapy or medication management when their needs are outside the PCP scope of practice. Call CalOptima Behavioral Health at
855-877-3885.
Note: For exchange of information back to the PCP, include signed member Consent to Release of Information. Fax: 866-422-3413
Referral for Orange County Specialty Mental Health Services: Refer members with SEVERE level of functional impairment to
county mental health services. Call the Orange County Mental Health Plan Access Line at 800-723-8641.
Note: For exchange of information back to the PCP, include signed member Consent to Release of Information. Fax: 866-422-3413
Referral for Substance Use Disorder Services: Refer members with substance use disorders and SBI referrals. Call CalOptima
Behavioral Health at 855-877-3885.
PCP Decision Support: Request a telephone consultation with a Beacon psychiatrist to provide decision support related member
diagnostic and medication clarification or other clinical decision supports. Include medication list and last two PCP progress notes for
psychiatrist review before phone consult with PCP. Fax: 866-422-341; Email: Medi-CalReferral@beaconhs.com
Updated 06/2015
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Mental Health Level of Care Screening Tool PCP (CalOptima)

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Completed 11 March 2021

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