Services – Angel Hands Behavioral Health

Our Team Provides:

• Mental Health Counseling

• Crisis Counseling

• Community Resources

• Family Therapy

• Alcohol & Drug Treatment

• Child & Adolescent Services

• Grief & Loss Counseling

• Psychiatric Evaluation & Medication Management

Angel Hands Behavioral Health provides support and care for behavioral issues. We offer a broad range of services for adults, seniors, and adolescents (13 and older) struggling with mental health and substance abuse problems while recognizing our patients’ diverse needs and the value of treating the whole individual, mind, body, and soul.

AHBH Enrollment Form

Step 1 of 10

Who are your requesting services for?(Required)

DEMOGRAPHIC INFORMATION

Name:(Required)

First Last

Parent/Guardian's Name:(Required)

First Last

Email:(Required)

Preferred language:(Required)

Contact Phone Number:(Required)

Living Situation:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Consumer Date of Birth:(Required)

Insurance Type:(Required)

Social Security Number:(Required)

Gender Identity:(Required)

Are you currently pregnant?(Required)

Ethnicity:(Required)

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

Prefer Not to Say

Select all that apply.

Employment Status:(Required)

Highest Level of Education:(Required)

Current Grade Level:(Required)

Marital Status:(Required)

Number of Dependent Children:(Required)

Are you a veteran?(Required)

Are you a hurricane victim?(Required)

Have you been arrested in the last 30 days?(Required)

Primary Source of Income:(Required)

Have you attended any self-help groups 30 days?(Required)

Frequency(Required)

Do you know the consumers Primary Care Physician's (PCP) information?(Required)

Do you know the consumers Emergency Contact information?(Required)

Is the referred currently receiving Mental Health Services?(Required)

Programs for Enrollment:(Required)

Therapy/Medication Management (OMHC)

Psychiatric Rehabilitation (PRP)

Who is making this referral:(Required)

REFERS INFORMATION

Organizations/Agency's Name:(Required)

Refers First Name:(Required)

Refers Last Name:(Required)

Contact Phone Number:(Required)

Email Address:(Required)

Relationship to Referred:(Required)

PRIMARY CARE PHYSICIAN

Do you have the PCP's Information?(Required)

Providers Name:(Required)

Contact Phone Number:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name:(Required)

First Last

Phone Number:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Email:

Relationship to Referred:(Required)

PRP ENROLLMENT

Is the consumer currently enrolled in any of the following programs:(Required)

Mobile Treatment Services (MTS) Assertive Community Treatment (ACT)

Adult Targeted Case Management (TCM)

Inpatient

MH- Residential Treatment Center (RTC)

Residential SUD Treatment Level 3.3 and Higher

SUD IOP/ 2.1

MH IOP/PHP

Residential Crisis

N/A

Unfortunately, due to changes with Medicaid through Optum Health, individuals who are currently active in these services will not be authorized for PRP. Once this individual has been discharged from services, please feel free to reapply. We do apologize for any inconvenience. If further assistance is needed, please feel free to contact our office during regular business hours.

Unfortunately, only a licensed mental health provider is able to make referral for these services. We do apologize for any inconvenience. If further assistance is needed, please feel free to contact our office during regular business hours.

PROVIDER INFORMATION

Is this an initial or or concurrent request?(Required)

Referring Clinician's Name:(Required)

First Last

License Type:(Required)

License Number:(Required)

Are you the clinical treatment provider for this consumer?(Required)

Do you have permission from the treating clinician to refer identified consumer for Psychiatric Rehabilitation services?(Required)

Clinical Supervisor's Name:(Required)

First Last

Clinical Supervisor's License Type:(Required)

Duration of current episode of treatment provided to this individual:(Required)

Current frequency of treatment provided to this individual:(Required)

Have they received PRP services from another PRP in the last 12 months?(Required)

PRP ADOLESCENT INFORMATION

Primary Diagnosis:(Required)

Is the individual eligible for full funding for Developmental Disabilities Administration services?(Required)

Have family or peer supports been successful supporting this youth?(Required)

Is the primary reason for the youth's impairment due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?(Required)

Has the participant been judged to be in enough behavioral control to be safe in a PRP program and benefit from the rehab provided?(Required)

Will the youth's level of cognitive impairment, current mental status or developmental level impact their ability to benefit from PRP?(Required)

Is the youth currently in mental health outpatient or inpatient treatment?(Required)

Is the referral source in some way paid by the PRP program or receives other benefit from PRP program?(Required)

The youth has been engaged in active, documented outpatient treatment for:(Required)

DOUBLE CHECK

Frequency of Clinical Treatment:(Required)

Date of Clinical Collaboration:(Required)

How long has the youth been engaged in active, documented, outpatient treatment?(Required)

Double CHECK

In the past 3 months, how many ER visits has the youth had for psychiatric care?(Required)

Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting?(Required)

Has medication been considered for this youth?(Required)

Within the past 3 months, the emotional disturbance has resulted in:(Required)

A clear, current threat to the youth's ability to be maintained in their customary setting

An emerging risk to the safety of the youth or others.

Significant psychological or social impairments causing serious problems with peer relationships and/or family members

Select all the apply. List objective evidence in this form, even if other evidence will be attached to this request.

Evidence of clear, current threat to the youth's ability to be maintained in their customary setting:(Required)

Evidence of emerging risk to the safety of the youth or others:(Required)

Evidence of significant psychological or social impairments causing serious problems with peer relationships and/or family members:(Required)

What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth's symptoms and functional behavioral impairments resulting from mental illness?(Required)

Has youth made progress toward age appropriate development, more independent functioning living skills?(Required)

Indicate changes in treatment plan to address lack of progress:(Required)

Describe Improvement:(Required)

How will PRP serve to help this youth get to age appropriate development, more independent functioning and independent living skills?(Required)

Has a crisis plan been completed with family and/or guardian?(Required)

Has an individual treatment plan/individual rehabilitation plan been completed?(Required)

Is the participant/guardian involved in preparation of the plan?(Required)

Is the participant/guardian in agreement of the plan?(Required)

PRP Adult Information

Primary Diagnosis:(Required)

Which type Dx does the consumer have:(Required)

Is the individual currently enrolled in SSI/SSDI?(Required)

Is the individual eligible for full funding for Developmental Disabilities Administration services?(Required)

Is the primary reason for the participant's impairment due to an organic process or syndrome, intellectual disability, a neurodevelopment disorder or neurocognitive disorder?(Required)

Is individual currently receiving mental health treatment from a licensed mental health professional or being referred from inpatient, mental health residential crisis, or mobile treatment services/assertive community treatment program?(Required)

Does the participant have marked inability to establish or maintain competitive employment?(Required)

Evidence of marked inability to establish or maintain competitive employment:(Required)

Does the participant have marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management)?(Required)

Evidence of marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management):(Required)

Does the participant have marked inability to establish/maintain a personal support system?(Required)

Evidence of marked inability to establish/maintain a personal support system:(Required)

Does the participant have deficiencies of concentration/ persistence/pace leading to failure to complete tasks?(Required)

Evidence of deficiencies of concentration/ persistence/pace leading to failure to complete tasks:*(Required)

Is participant unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)?(Required)

Evidence of inability to perform self-care (hygiene, grooming, nutrition, medical care, safety):(Required)

Does the participant have marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities?(Required)

Evidence of marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities:(Required)

Does the participant have marked inability to procure financial assistance to support community living?(Required)

Evidence of marked inability to procure financial assistance to support community living:(Required)

Has participant demonstrated marked functional impairments for at least 2 years?(Required)

Has consideration been given to using peer supports and other informal supports such as family?(Required)

Has participant been judged to be in enough behavioral control to be safe in rehab program and benefit from the rehab provided?(Required)

List specific ways in which PRP services are expected to help this individual:(Required)

OMHC ENROLLMENT

Is the Individual Deaf or hard of Hearing?(Required)

Is the Individual Blind or Having Serious Difficulty Seeing, even when Wearing Glasses?(Required)

Because of a Physical, Mental, or Emotional Condition, is the Individual having Serious Difficulty Concentrating, Remembering, or Making Decisions? (5 years old or older)(Required)

Is the Individual Having Serious Difficulty Walking or Climbing Stairs?(Required)

Because of a Physical, Mental, or Emotional Condition, is the Individual Having Serious Difficulty doing Errands Alone such as Visiting a Doctor's Office or Shopping? (15 years old or older)(Required)

Was the Individual Screened for Gambling?(Required)

SUBSTANCE ABUSE INFORMATION

The consumer has/had a substance use or addiction:(Required)

The consumer has psych problems in addition to alcohol, drugs, or addiction:(Required)

Primary Substance of Use:(Required)

Age at First Use:(Required)

Route of Administration:(Required)

Frequency of Use:(Required)

Date of Last Use:(Required)

Attestation:(Required)

Attestation: I attest all of the information provided is accurate and reflected in the participant's medical record.

Signature:(Required)

Please attach documentation needed to support services for this consumer:

Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.

(Ex: Treatment Plans, Assessments, Discharge Summaries, Court Order, etc.)

Date

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