NCBH Linkages Request

Behavioral Health Linkages Request

The purpose of this form is to start the process of behavioral health linkages for an incarcerated person. Referrals will be accepted from correctional facilities and CalAIM Jail Linkages Coordinators.
Requesting Entity Information

This section is for an agency requesting Behavioral Health linkage for an inmate in your jail system.
Requester Name

First NameLast Name
Requester Email
example@example.com
What county are you requesting service from?
What kind of facility is the person currently in?
Phone number of facility or main contact
Please enter a valid phone number.
Physical address of the person in the facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Information
Client Name

First NameLast Name
Client Medi-Cal #
Client Medi-Cal County of Insurance
Client Date of Birth

MonthDayYear
Date
Client Email
example@example.com
Phone number upon release
Please enter a valid phone number.
Is the person on any medication?

YesNo
Prescribing Doctor
Prescription Location
What is the person's housing situation at release?

Living in a place not meant for human habitation (street/car/river/camp/etc.)ShelterTransitional HousingExiting to Other InstitutionNot Homeless (Housed)
Client Address at Release

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Scheduling and Coordination
Facility entry date

MonthDayYear
Date
Expected release date from the facility

MonthDayYear
Date
Can your facility accommodate telehealth appointments?

YesNo
Please provide any set up or technology issues we should we aware of
What times of the day are best for contacting the client regarding linkages?

6am-10am10am-2pm2pm-6pm6pm-10pm
Below are Nevada County's Preferred Screening Tools
For adults with a suspected substance use need, please complete a BQuip and attach the result: BQuiP Document
The Adult Screening and Transition of Care Tools for Medi-Cal Mental Health Services ensures that Medi-Cal members are direted to the most approrate level of treatment(Managed Care Plan or County Mental Health Plan).
The Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services ensures that Medi-Cal members are direted to the most approrate level of treatment(Managed Care Plan or County Mental Health Plan). This is appropate for youth 20 years and younger.
If the referred individual is justice involved and was screened for Managed Care Plan (MCP), contact Ron Klinger at rklinger@partnershiphp.org and upload the MCP document.
Referral Information
Universal Screening Tool for Level of Care

Cancelof
BQuiP

Cancelof
Medical Record

Cancelof
Release of Information

Sharing of information is allowable under coordination of care without Release of Information. If ROI is available and signed, upload here.
Cancelof
By submitting this form, I agree this information is accurate and I am making the referral as an approved entity through CalAIM.*

Yes
Should be Empty:

Behavioral Health Linkages Request

Requesting Entity Information

Client Information

Scheduling and Coordination

Below are Nevada County's Preferred Screening Tools

Referral Information