Trillium/STAR Referral (County Detention Centers)

Trillium/STAR Referral (County Detention Centers)

STAR (Support Transition and Reentry) provides support to incarcerated adults with behavioral health conditions by coordinating re-entry, transitional/permanent housing options, tailored care mgt., peer support, linkage to clinical & community-based services, supported employment, and community integration for individuals who meet the following Criteria…

Age 18 or Older
Incarcerated and expected to Release in 30-90 days to Trillium Catchment OR is ITP wait listed for State Hospital
View Trillium catchment: https://www.ncdhhs.gov/providers/lme-mco-directory
Eligible for Trillium Medicaid (Trillium will verify Medicaid status. Medicaid does not need to be active, however individuals enrolled in Medicaid with an external agency or Standard Plan can't be accepted)
Diagnosis of Serious Mental Illness (SMI) or Intellectual/Developmental Disability (IDD) (*Secondary substance use or other co-occurring diagnoses accepted, but SU is not the only diagnosis). SMI includes Schizoaffective, Schizophrenia, Borderline Personality disorder, Delusional disorder, Major Depressive d/o (recurrent moderate or severe) Other diagnoses may be considered with clinical review *Alzheimer’s/Dementia & Severe TBI are excluded from STAR

*Clinical documentation confirming diagnosis is required

Questions? Contact Trillium STAR Director, Erin Kinsel at 252-751-8584 or erin.kinsel@trilliumnc.org

Individual Name*

DOB*

Date of Referral*

Legal Guardian?*

Yes

Unknown

Guardina Name & Contact #*

Detention Center or Correctional Facility Name*

Referrer Name*

Referrer Phone #*

Referrer email

Expected Release date

If exact release date unknown, explain:*

Provide as much info as possible (i.e. "expected to release in 30-45 days" or "next court date is 2/1/24, charges likely to be dismissed")

Anticipated County of release*

What county is the individual expected to release to?

Attorney or PPO Name & Phone # (if applicable)*

If no probation, write in none or N/A

Current Criminal Charges or Convictions*

List current charges and/or convictions

Treatment History, Current Community Provider*

List any Current Community-Based Mental Health Provider (is ACTT/CST coming in to the jail to see individual?), list any known treatment providers prior to incarceration. Please list services received and what agency provides the service . If no providers are known, write in "none" or "unknown"

MAT/MOUD or prescribed Clozaril/Clozapine*

Is the individual receiving MAT or MOUD for substance use at the jail such as: Suboxone, Subutex, Sublocade, buprenorphine, methadone, Vivitrol, naltrexone).

Is the individual prescribed Clozaril/Clozapine currently?

Select

Current Diagnoses*

Please list all current behavioral health, substance use and medical diagnoses

Medications administered at Detention Center*

Please list all current medications (if none, write in "none")

Other Relevant info*

Please list any attorney's involved, court dates, reason for referral, past charges, housing situation prior to incarceration & at release, immediate needs, family/friends involved in their life/care, and any other relevant info

File Upload*

Attach the Detention Center Assessment, Clinical Documents, or Medical Records confirming diagnosis

*Referral will not be accepted if this information is missing

Drag and drop files here or

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