Crisis Stabilization Referral — Children

For individuals 5 through 17 years of age experiencing a mental health crisis who do not meet criteria for inpatient psychiatric services and need further stabilization. Must be screened by a provider prior to admission. This is a voluntary program that does not accept court-ordered patients.

* Required fields

Call first to confirm availability

Please call 515-642-7070 (Perry) first to confirm bed availability, then complete and submit this form.

You may also fax completed referrals to 515-666-4340.

Conditions that may prohibit admission

Pending arrest or warrant
Evaluated and determined to need inpatient psychiatric services
Acute medical needs
High risk of violence
Not medication compliant
Needing assistance completing activities of daily living
Listed on the sex offender registry

Referral Information

Name *

Birthdate *

Current / Last Known Residence *

City *

County

Legal Guardian Name *

Guardian Phone Number *

Required for all minors. Guardian must be reachable throughout the stabilization stay.

Case Manager

Phone Number

MCO / Insurance Provider

Policy Number

Allergies — food and medication

Substance Use Screening

Has the individual tested positive or self-reported any substance use in the last 24 hours? *

Yes No

If yes, please describe

Clinical Information

Mental Health / Substance Use Disorder Diagnosis

Current Mental Health Provider — Name & Contact Info

Current SUD Provider — Name & Contact Info

Reason for Referral *

Current Observable Behaviors

Vitals

Time of Vitals

Blood Pressure

Heart Rate

Temperature

UA Positives

BAC

Medical & Medications

Current Medical Conditions

Current Medications

Please send at least a 7-day supply of medications for client — required for acceptance.

Discharge Planning

Discharge Plan / Location *

Guardian must approve discharge location and must sign discharge paperwork.

Referring Provider

Referring Organization *

Referring Contact *

Contacted upon approval or denial.

Phone Number *

Additional Comments

Guardian Checklist Required

The checklist on the last page must be completed by the client's guardian for staff to consider the referral.

Guardian Acknowledgment

I acknowledge that I have reviewed the admission criteria and believe that the individual is appropriate for services. Guardian must approve discharge location and sign discharge paperwork. *

Guardian Name

Provider Acknowledgment

I acknowledge that I have reviewed the admission criteria and believe that the individual is appropriate for services through Inside Out Wellness and Advocacy. *

Referring Provider Name

Your referral will be reviewed by the Inside Out team. You will be contacted regarding approval or denial.