Multnomah Crisis Assessment and Treatment Center (CATC) Referral Form

Note: Thank you for your interest in Telecare’s Multnomah Crisis Assessment and Treatment Center. We are here to serve adults 18 years and older in a mental health crisis who are covered by Care Oregon or referred by Multnomah County Call Center (Multnomah County Treatment Fund). The service area for Care Oregon clients is those who live in Clackamas, Washington, and Multnomah counties.

If you are a provider of an uninsured individual with Medicare only, please do not use this form. Instead, complete the Multnomah County Referral form on our website and send it to CATCreferrals@multco.us. or call 503-988-4888 for more information. Please do not use this form.

CATC services intend to divert Members from unnecessary hospitalizations, incarcerations, state hospital admissions, and evictions from community-based residential treatment programs and provide step-down care after acute hospitalization for Members who need further stabilization to ensure successful functioning in the community.

Please submit a complete referral form with supporting documentation to be considered for admission. You will receive an email confirmation of your submission. From 8 am-5 pm, we strive to decide on submitted referrals within 2 hours. Referrals received after 5 pm will be responded to the following morning. If your referral is accepted or we need more information, we will call the number or send an email you provide. If the referral is declined, you will receive an email with the reason for denial and the process for reconsideration.

*Press the TAB button to skip to the next item on the form.

***Referrals can be submitted 24 hours a day, any day of the week.

*** This platform is HIPAA compliant and can accept PHI. Please ensure you have an appropriate release of information from the person you refer to.

Referral Screening Information

First and last name of potential resident*

Legal Name if different than above

Address of resident*

Please specify if the person is currently unhoused

Phone number of resident

If applicable

DOB*

Social Security Number

If available

Mental Health Insurance*

Select

Was this referral submitted to Multco Crisis Line?

Select

Physical Health Insurance

Select or enter value

Insurance ID*

Name Referent:*

Phone Number of Referent:*

Email of Referent*

Provider Type*

Select

Referral Source*

Select or enter value

County of residence*

Select

Patient Information

Gender Identity*

Pronouns*

Race/Ethnicity

Select

Assigned Sex at Birth

Select or enter value

Legal Status*

Select or enter value

Start/End date of legal status

Probation/Parole

Select

Name/number of PO, or ICP investigator, guardian

Were police involved in transport to hospital?*

Select or enter value

Presenting Problems and symptoms*

What is the current crisis? Please include if the person is experiencing acute psychosis/disorganization.

ICD-10 Provisional Diagnosis:*

Medical Considerations

Substance use history:*

Frequency/last use

Residential treatment referral needed?

Select or enter value

Urine Drug Screen, or Blood Alcohol Level?

Emergency Dept only. Please provide applicable findings.

Medical Diagnoses:*

Medications taking to address medical issues:*

Known Allergies:*

Dietary needs/preferences*

We will do our best to accommodate.

Bedbugs/Lice/Scabies in last 12 months?*

Select or enter value

If yes, dates treated

PPD/TB test completed*

Completed within the last 12 months and available?

Select or enter value

Hepatitis B screening test completed?*

Completed within the last 12 months and available?

Select or enter value

Screened for COVID?*

Select or enter value

COVID 19 vaccine administered?*

Select

Does this person want a COVID Vaccine?

Select

Ambulatory?*

Can the person evacuate by stairs in less than 3 minutes?

Select or enter value

Please describe mobility needs

Can the person descend 29 stairs unassisted?*

Select or enter value

Does the person need verbal cueing?*

Examples; for ADL's or in an emergency?

Is this person independent with ADL's?*

Select

Please describe ADL needs:

Areas of Risk

Suicidal Risk?*

Select

Previous Suicide/Self Harm Attempts?*

Select

Please Describe

Current Plan/Means?*

Select

What is their current plan?

Able/willingness to stay safe in current setting?*

Select

Dangerous/combative towards others?*

Select

Please describe danger to others

History of sexual behaviors/vulnerabilities*

sexual preoccupation, hyper sexuality, sexual trauma, history of sexual offense, other sexual behaviors that require risk mitigation support.

Select or enter value

Describe sexual behavior that require monitoring

Is this person safe sharing a room?*

Select or enter value

What type gender(s) would they share a room with?*

Select

Other things to consider for room assignment?

We will do our best to accommodate

Discharge Planning

What discharge plan has been started?*

Select or enter value

Primary Care Provider*

Name and contact number

Mental Health Provider*

Name and contact number

Is the person connected to care coordination?

Select or enter value

Name/number of primary care coordinator

Emergency Contact*

Name and contact number

Please Attach Supporting Documentation*

**Multiple files can been attached** A COMPLETE REFERRAL includes: Mental health assessment Documentation of current mental health exam (last 24hrs) Recent progress notes Current and complete med list or MAR History and Physical If Available: Recent Labs

Drag and drop files here or

Send me a copy of my responses

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