Community Oriented Recovery and Empowerment (CORE) Services Referral

Please complete as much of the form below as you are able to in order to ensure that MHA is able to follow up and provide CORE services promptly upon receipt of this referral.

Referring Individual's Name: Referring Individual's Name: First Last
Referring Individual's Phone Referring Individual's Phone - ### - ### ####
Referring Individual's Email
Relationship To Individual Being Referred for CORE Services

a Licensed Practitioner of the Health Arts (LPHA), as defined by:
• Nurse Practitioner
• Physician
• Physician Assistant
• Psychiatric Nurse Practitioner
• Psychiatrist
• Psychologist
• Registered Professional Nurse
• Licensed Mental Health Counselor
• Licensed Creative Arts Therapist
• Licensed Marriage & Family Therapist
• Licensed Psychoanalyst
• Licensed Clinical Social Worker
• Licensed Master Social Worker, under the supervision of an LCSW, licensed psychologist, or psychiatrist employed by
the agency
Referring Agency Name
Referring Agency Address Referring Agency Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
If Other is selected please provide a description of your relationship to the person being referred for services:
Name of Individual being referred for CORE services: Name of Individual being referred for CORE services: First Last
Phone of Individual being referred for CORE services: Phone of Individual being referred for CORE services: - ### - ### ####
Email of Individual being referred for CORE services:
Address of Individual being referred for CORE services: Address of Individual being referred for CORE services:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Social Security #of Individual being referred for CORE services:

Please enter numbers only - no dashes.
Date of Birth of Individual being referred for CORE services: Date of Birth of Individual being referred for CORE services: / MM / DD YYYY
Primary Language of Individual Being Referred for CORE Services:
Gender Pronouns of Individual Being Referred for CORE Services:
Managed Care Organization (MCO) Name:
MCO ID#
MCO Contact Name MCO Contact Name First Last
MCO Contact Phone MCO Contact Phone - ### - ### ####
MCO Contact Email
Medicaid CIN Number:
Primary diagnosis & ICD 10 code of Individual being referred for CORE services
Secondary diagnosis & ICD 10 code of Individual being referred for CORE services
Any Known Safety Concerns? (Criminal Record, History of Violence, Weapons in the Home, Sex Offender, General Concerns, etc.):
Referred CORE Service(s):

Referred CORE Service(s): Family Support Servies Psycho-Social Rehabilitation (PSR) (Includes Social, Habilitational, Educational, and Vocational Services)
Name of Individual's Mental Health Provider (LPHA) Name of Individual's Mental Health Provider (LPHA) First Last
Phone number of Individual's Mental Health Provider (LPHA) Phone number of Individual's Mental Health Provider (LPHA) - ### - ### ####
Email of Individual's Mental Health Provider (LPHA)
Name of Individual's Care Manager/Coordinator Name of Individual's Care Manager/Coordinator First Last
Phone number of Individual's Care Manager/Coordinator Phone number of Individual's Care Manager/Coordinator - ### - ### ####
Email of Individual's Care Manager/Coordinator
Reason for CORE Referral

Please list why you are making this referral for CORE services and what you, or the person you are making the referral for, is hoping to receive from these services.