Coordinated Specialty Care

Name(Required)

First

Last

Gender

Pronouns

Phone number (include area code)

Phone Number

Home

Cell

Enter Email Confirm Email

Date of Birth(Required)

Parent (if applicable)

First

Last

Phone number (include area code)

Phone Number

Home

Cell

Legal Guardian (if applicable)

First

Last

Phone number (include area code)

Phone Number

Home

Cell

Emergency Contact(Required)

First

Last

Phone number (include area code)(Required)

Phone Number

Home

Cell

Relationship

Is the person aware you're making this referral?

Yes

If person is aware of referral, how does the person feel about being referred?

Agreeable

Uncertain

Uninterested – engagement needed

If no, how can we best coordinate?

Primary Language/Interpreter Needs(Required)

Additional Cultural Considerations

Referring Party(Required)

First

Last

Agency

Email(Required)

Enter Email Confirm Email

Phone number (include area code)(Required)

Reason for Referring to CSC (why is this service level needed, how do you hope it will help the person)(Required)

The CSC program requires that the person has experienced psychotic symptoms within the last 1-2 years. Early serious mental illnesses are mental (ESMI), behavioral, or emotional disorders that affect an individual regardless of their age and interfere with that individual’s development and daily functioning. Examples include schizophrenia and schizoaffective disorder. First episode psychosis is one of the mental health conditions considered ESMI. FEP (first episode psychosis) refers to the initial onset of symptoms of psychosis.

Please check all that apply

Hallucinations: Sensory experiences such as hearing voices or sounds, smells, tastes, visuals, distortions or tactile feelings that others cannot perceive.

Delusions: Unusual beliefs that can lead to high levels of fear, anxiety or paranoia for no apparent reason or an unfounded reason; episodes of depersonalization (e.g. belief that they do not exist or that their surroundings are not real); belief that other people are putting thoughts in their head, stealing their thoughts, can hear their thoughts out loud or can read their minds (or vice versa).

Negative Symptoms: Includes difficulty experiencing pleasure, feeling motivated or enjoying activities like they used to; flat affect; significant decline in either academic, vocational, social or personal (e.g. sleep, hygiene) functioning.

Thought Disorder/Disorganized Communication: Including flight of ideas, rapidly shifting between topics, tangential, unusual word choice or pattern of expression, repetition of words or ideas, accelerated or slow processing, thought blocking, nonsensical or incoherent speech, etc.

Grossly disorganized or catatonic behavior: Can include difficulty in goal-directed behavior, unpredictable agitation or silliness, social disinhibition, abnormal motor behavior (e.g. rigidity, bizarre posture, pacing), or marked decrease in reactivity to environment (e.g. mutism, stupor).

Other noted diagnoses

Does the individual have a current diagnosis?

Yes

If so, please provide DSM/ICD Diagnosis and Code Date of Diagnosis.

Primary Care Provider Name

First

Last

Clinic

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number (include area code)

Mental Health Care Provider Name

First

Last

Clinic

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number (include area code)

Current medications, include name and dosage (include medication list if possible). Please include where prescriptions are currently being filled.

Other supports (i.e. academic, legal or community supports such as school counselor, probation officer, CPS, coach, mentor, cultural or spiritual advisors)

Previous Outpatient Providers and/or mental health providers or services (please include name, location, and dates of receiving services to the best of your ability)

Does the person frequently use emergency services?

Yes

If yes, please provide most recent dates and reasons

Is the person homeless?

Yes

If yes, how long have they been homeless?

Does the person have involvement with the Criminal Justice System?

Yes

If yes, please explain

Does the person have a history of violent/aggression/assault?

Yes

If yes, please explain

If available, include the following records. If not available, we may need to work with you and the individual to get records before making an eligibility determination.

Diagnostic Assessment (within one year)

Current and Historical Hospitalization Records/Dates

Civil Commitment/Prepetition Paperwork (current/historical)

File

Max. file size: 64 MB.

Coordinated Specialty Care

Coordinated Specialty Care

Wisconsin Headquarters

Minnesota Headquarters

Viroqua Offices

Black River Falls Offices

Sparta Offices

Mailing List

Mailing List

Social Media