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  • Referral To in Home Outreach Team (IHOT) : 408-375-2788 Cassie Bishop SCC IHOT For

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    This referral form provides demographic and clinical information for a client being referred to the In Home Outreach Team (IHOT). It includes the client's name, address, date of birth, emergency contact, housing, transportation ability, medical issues including asthma, COPD, diabetes and substance use history. The form also notes the client's mental health diagnosis, any safety concerns like history of violence or weapons, and the reason for referral which is that the client meets IHOT program eligibility criteria based on emergency psychiatric services visits in the past 12 months.

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    This referral form provides demographic and clinical information for a client being referred to the In Home Outreach Team (IHOT). It includes the client's name, address, date of birth, emergency contact, housing, transportation ability, medical issues including asthma, COPD, diabetes and substance use history. The form also notes the client's mental health diagnosis, any safety concerns like history of violence or weapons, and the reason for referral which is that the client meets IHOT program eligibility criteria based on emergency psychiatric services visits in the past 12 months.

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    5 views1 page

    Referral To in Home Outreach Team (IHOT) : 408-375-2788 Cassie Bishop SCC IHOT For

    Uploaded by

    lindsay cross
    This referral form provides demographic and clinical information for a client being referred to the In Home Outreach Team (IHOT). It includes the client's name, address, date of birth, emergency contact, housing, transportation ability, medical issues including asthma, COPD, diabetes and substance use history. The form also notes the client's mental health diagnosis, any safety concerns like history of violence or weapons, and the reason for referral which is that the client meets IHOT program eligibility criteria based on emergency psychiatric services visits in the past 12 months.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Date of referral_____________

    Referral to In Home Outreach Team (IHOT)


    Cassie Bishop
    Referring Provider Name ___________________Agency Scc IHOT for
    ____________________Contact 408-375-2788
    Phone # ______________________

    Client Demographic Information

    English
    Client Name ________________________________________________ Language_________________________________

    Address ________________________________________ Cell#_________________________ Home# ___________________

    DOB _____/_____/_____ Sex ____ Race _________ Marital Status----Single Married Divorced Widowed 

    MRN# _________________ Unicare# ______________ Insurance---Medical Medicare Other _________________

    Emergency Contact Name_______________________ Relationship to Client___________________ Phone# _____________

    Current Housing Type (B&C, SNF, Group home, Homeless, etc.) _________________________________ Veteran Yes No
    Unknown
    Describe client’s ability to transport self:______________________________________________________________________

    PFN#________________________________ CDCR ______________________________

    Clinical and Medical Information

    Does client have any of the following issues:

    Asthma COPD Diabetes Other Major Medical Issues____________________________________________

    Hx of substance use/drug of choice:__________________________________________________________________________

    Mental Health Diagnosis ___________________________________________________________________________________

    Does client have any of the following:

    Service Animal Wheelchair Learning Disability History Of Violence Weapons

    Reason for referral (include why you believe they are eligible for IHOT services)
    Individual meets the eligibility criteria for the IHOT program. EPS visit/s in the past 12 months, most recent
    admission
    SSN #

    Safety Concerns

    IHOT 2019

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