TBS REFERRAL CHECKLIST
Keep in mind the Referral Criteria when making a referral for TBS. If you have questions about the criteria, please feel free to call us at our TBS program site: (909) 433-0445. The following is a list of the Eligibility Requirements for making a TBS Referral:
The client must meet A and B requirements
A. Full-scope Medi-Cal beneficiary under the age 21
B. One must also be currently receiving specialty mental health services.
Client must meet A, B, C or D requirements
A. Placed in a group home/Residential Treatment Center (RTC), RCL 12 or above.
B. Being considered for or “at risk for” placement in a group home/RTC RCL 12 or above.
C. At least one emergency psychiatric hospitalization, or “at risk for hospitalization” related to the current presenting disability within the past 24 months.
D. Previously received behavioral services through TBS.
TBS is provided to prevent placement in a
higher level of residential care, repeated hospitalization, or to ensure a successful transition to a lower level of residential care.
In order to accept a TBS referral, the following forms must be completed fully. These forms can be found below in PDF format. You may download and print these forms, and then fax them to our MHS Inc., TBS San Bernardino site at (909) 433-0556. Please be sure to fill all forms in their entirety, and sign all forms so that there is no delay in processing your referral.
If the client is residing in the family home please complete the follow forms (Forms 1,2, and 3 in the pdf files below):
• TBS “REFERRAL” (1)
• Risk Assessment (2)
• A signed “AUTHORIZATION FOR RELEASE AND EXCHANGE OF CLIENT PROTECTED HEALTH INFORMATION” (3) for the referring party.
If the client is residing in a foster home, group home or other residential placement, the above forms (forms 1,2, and 3) must be submitted, signed by the SSSP or Conservator or person authorized to sign for the client. Additionally, the following forms (forms #4 and 5) must be completed and signed. Please also send a minute order that authorizes the individual to sign for the client.
• TBS SanBernardino “AUTHORIZATION FOR TREATMLENT AND SERVICES” (4)
• “CONSENT FOR THE RELEASE OF CONFIDENTIAL MENTAL HEALTH INFORMATION TO MULTI-SERVICE CONSORTIUM.” (5) (DCS Clients)
Please understand that we want to process your referral as quickly as possible, however, we must have all forms completed in their entirety for the referral to be considered to be made. Please be sure all forms are completed and that appropriate dates and signatures are present.
TBS Referral Form
This form must be completed by all individuals making a referral to TBS San Bernardino. Please remember to fill out the form in it's entirety to delay processing of your referral. This form may be completed by Community Members, DCS Social Workers, Department of Behavioral Health staff, Clinicians, Teachers, School Officials, Family Members, Child Care Workers or Group Home Staff. TBS San Bernardino welcomes referrals from all sources within the community. (You may also want to print and view the Sample Instructional Referral Form [1 Sample] at the bottom of this page)
Document: TBS Referral Form (1)
TBS Risk Assessment
The TBS Risk Assessment must be completed by the referring party. Please fill it out to the best of your abilty and knowledge about risk issues for this client. Our TBS Case Management staff will complete another Risk Assessment during the assessment visit.
Document: TBS Risk Assessment Form (2)
Authorization for Release and Exchange of Information
This is our Consent to Release and Exchange Information to and from TBS San Bernardino and our Referring party. Please fill this form in its entirety and inital every area that you are consenting to release. Please remember to provide an expiration date. The form must be signed by the person who is legally authorized to sign for the minor or by the client if they are 18 years or older.
Document: Authorization for Release and Exchange of Information (3)
TBS Consent for Treatment
If the client is residing in a foster home, group home or other residential placement, this consent forms must be submitted with your referral. It is to be signed by the SSSP or Conservator or person authorized to sign for the client. Please also send a minute order that authorizes the individual to sign for the client. Additionally, the following forms must be signed:
(You may also want to print and view the Sample Instructional Consent for Treatment [4 Sample] at the bottom of this page)
Document: TBS Consent for Treatment (4)
Consortium Release for Multiple Parties
This Release of Information is especially useful to Clients who are placed out of the home and have the need for Consents or Releases of Information to be made to multiple parties. We encourage referrals that need to be signed by Supervising Social Workers for children in placement to utilize this consent form. We also encourage this form to be used by those who require consents to release confidential information for multiple parties. (You may also want to print and view the Sample Instructional Consortium Release [5 Sample] at the bottom of this page).
Document: Consortium Release for Multiple Parties (5)
Checklist for At Risk of Hospitalization
At Risk for Hospitalizaion
This form is to be used when the client meets criteria for a referral by being "at risk" for hospitalization. This form is not necessary if the client has been hospitalized within the last 2 years, or has been placed in an RCL 12 Group Home within the past 2 years. This must be signed by a Licensed Clinician or Supervising Social Worker
Document: At Risk for Hospitalization
Checklist for RCL 12 Placement
At Risk for Placement in an RCL 12
This form is to be used if the client meets criteria for a referral because they are "at risk" for placement in an RCL 12 Group Home. This is not necessary to be filled out if the client has been hospitalized within the last 2 years, or if they have been placed in an RCL 12 Group Home within the past 2 years. This must be signed by a Licensed Clinician or Supervising Social Worker
Document: At Risk for RCL 12 Placement
Checklist for Expedited TBS Request
Checklist for Expedited TBS Request
This checklist is to be used if you are requesting an urgent request for expedited TBS services. All TBS requests are urgent in nature. However the Expedited TBS Request is suggesting that this request is especially urgent due to an immediate potential loss of placement for a child or other matter of urgency.
Document: Checklist for Expedited TBS Request
SAMPLE INSTRUCTIONAL FORMS
The following three forms are Sample Instructional Forms for some of the above forms. These are the forms that most often delay our referral packets because they are not filled out in entirety. These Sample Instructional Forms may be printed and used as an aid to fill out the necessary referral forms for TBS.
Sample Instructional Referral Form
Sample Instructional Consent to Treatment
Sample Instructional Consortium Release to Multiple Parties
Never doubt that a small group of committed citizens can change the world. Indeed, it is the only thing that ever has.