Application - IRSH Referral Form

*Each question within this application must be fully answered.*

SECTION 1: Demographics

Date of Application:

Individual's First Name:

Individual's Last Name:

Current Address: (If homeless or in a facility, please list last known address.)

County:

Social Security #:

Gender:

Male

Female

Other

Date of Birth:

Month

Day

Year

Managed Care Organization (MCO):

State ID/MCO #:

Referral Source Information:

Name & Title:

Agency:

Phone #:

Email:

SECTION 2: Living Situation & Utilization History

Utilization History (12 Months Prior to Referral):

Correctional/Jail Stays (Past 12 Months): If applicable, list charge(s), facility name, and dates of stay.

Psychiatric Hospital Stays: (For Each Stay/Visit, Include the Name of Hospital/Facility, Admission/Discharge Dates, and Total Number of Days.)

ER Visits Related To A Psychiatric Diagnosis: (For each stay/visit, include the Name of Hospital/Facility, Admission/Discharge Dates, and Total Number of Visits.)

SECTION 3: Required Documents

Please upload all applicable documents below. A referral will not be considered complete until required documentation is received. Required documents must have been completed within the last 60 days.

Level of Care (LOCUS/Tier)

Upload your file

Choose a file or drag and drop one here.

Functional Assessment

Upload your file

Choose a file or drag and drop one here.

Diagnostic Assessment Confirming Primary SPMI

Upload your file

Choose a file or drag and drop one here.

Court/Legal Documents

Upload your file

Choose a file or drag and drop one here.

Recent Clinical Notes

Upload your file

Choose a file or drag and drop one here.

Upload your file

Choose a file or drag and drop one here.

If you are unable to upload documents, please send all referral documents in one email, if possible, to: irshreferrals@firstresources.us

SECTION 4: Legal & Funding Information

Legal Representatives?

Yes

Guardian: Name & Contact

Conservator: Name & Contact

Medical POA: Name & Contact

Payee: Name & Contact

Court Ordered to IRSH?

Yes

(If Court Ordered, specify if it is an Alternative Placement or Outpatient Order)

Funding Type:

Habilitation

Waiver

Other

Food Stamps:

Active

Application in Process

None

Other

Monthly Amount of Food Stamps:

SSI/SSDI:

Active

Application in Process

None

List Other Status

Monthly Amount of SSI/SSDI:

SECTION 5: Eligibility Screening

Describe the individual’s current clinical & functional presentation that requires 24-hour supervised & monitored support. Include specific needs related to safety, medication management, behavioral stability, ADLs, or inability to function independently.

Describe prior levels of care attempted (e.g., family living w/HCBS supports, RCF, etc.) and the individual’s response to those services. Include an explanation of why these settings were insufficient to maintain safety, stability, or functioning.

Please explain what is likely to happen if the individual does not receive Intensive Residential Services. Describe how the individual’s safety, stability, or ability to function may be affected.

Utilization/Special Circumstances Eligibility (Select all that Apply):

3+ Pychiatric Hospitalizations in the Past 12 Months Preceding Application

30+ Medically Necessary Psychiatric Hospital Days

90+ Psychiatric Hospital Days in the Past 12 Months Preceding Application

3+ Psychiatric ER Visits in the Past 12 Months Relating to a Psychiatric Diagnosis

Residing in a State Resource Center and a Serious & Persistent Mental Illness (SPMI)

Being Served Out-of-State due to the unavailability of Medically Necessary Services in Iowa

Has an SPMI and is Scheduled for Release from a Correctional Facility or County Jail

Is Homeless or Precriously Housed

Individual must be able to be admitted within 28 days of Referral. Is the individual willing and able to admit within this timeframe?

Yes

If no, explain anticipated timeline or barriers to admission:

Is the individual aware of and in agreement with this referral being submitted?

Yes

If No, Please Explain:

Additional Information (Optional) - Please provide any additional information that may assist in reviewing this referral.

We do not maintain a waitlist, but we encourage you to check current openings at: https://www.firstresources.us/hcbsservices

Please send all referral materials, additional documentation, or questions to: irshreferrals@firstresources.us

The First Resources Corp. Intensive Residential Services team is here to partner with you throughout the referral process as we work together to support the individuals we serve.

First Resources Corp. | 710 Gateway Dr., Ottumwa, IA

Phone: 641-682-8114

*Each question within this application must be fully answered.*

SECTION 1: Demographics

Date of Application:

Individual's First Name:

Individual's Last Name:

Current Address: (If homeless or in a facility, please list last known address.)

County:

Social Security #:

Gender:

Male

Female

Other

Date of Birth:

Month

Day

Year

Managed Care Organization (MCO):

State ID/MCO #:

Referral Source Information:

Name & Title:

Agency:

SECTION 2: Living Situation & Utilization History

Utilization History (12 Months Prior to Referral):

Correctional/Jail Stays (Past 12 Months): If applicable, list charge(s), facility name, and dates of stay.

Psychiatric Hospital Stays: (For Each Stay/Visit, Include the Name of Hospital/Facility, Admission/Discharge Dates, and Total Number of Days.)

ER Visits Related To A Psychiatric Diagnosis: (For each stay/visit, include the Name of Hospital/Facility, Admission/Discharge Dates, and Total Number of Visits.)

SECTION 3: Required Documents

Please upload all applicable documents below. A referral will not be considered complete until required documentation is received. Required documents must have been completed within the last 60 days.

Level of Care (LOCUS/Tier)

Upload your file

Choose a file or drag and drop one here.

Functional Assessment

Upload your file

Choose a file or drag and drop one here.

Diagnostic Assessment Confirming Primary SPMI

Upload your file

Choose a file or drag and drop one here.

Court/Legal Documents

Upload your file

Choose a file or drag and drop one here.

Recent Clinical Notes

Upload your file

Choose a file or drag and drop one here.

Upload your file

Choose a file or drag and drop one here.

If you are unable to upload documents, please send all referral documents in one email, if possible, to: irshreferrals@firstresources.us

SECTION 4: Legal & Funding Information

Legal Representatives?

Yes

Guardian: Name & Contact

Conservator: Name & Contact

Medical POA: Name & Contact

Payee: Name & Contact

Court Ordered to IRSH?

Yes

(If Court Ordered, specify if it is an Alternative Placement or Outpatient Order)

Funding Type:

Habilitation

Waiver

Other

Food Stamps:

Active

Application in Process

None

Other

Monthly Amount of Food Stamps:

SSI/SSDI:

Active

Application in Process

None

List Other Status

Monthly Amount of SSI/SSDI:

SECTION 5: Eligibility Screening

Please explain what is likely to happen if the individual does not receive Intensive Residential Services. Describe how the individual’s safety, stability, or ability to function may be affected.

Utilization/Special Circumstances Eligibility (Select all that Apply):

3+ Pychiatric Hospitalizations in the Past 12 Months Preceding Application

30+ Medically Necessary Psychiatric Hospital Days

90+ Psychiatric Hospital Days in the Past 12 Months Preceding Application

3+ Psychiatric ER Visits in the Past 12 Months Relating to a Psychiatric Diagnosis

Residing in a State Resource Center and a Serious & Persistent Mental Illness (SPMI)

Being Served Out-of-State due to the unavailability of Medically Necessary Services in Iowa

Has an SPMI and is Scheduled for Release from a Correctional Facility or County Jail

Is Homeless or Precriously Housed

Individual must be able to be admitted within 28 days of Referral. Is the individual willing and able to admit within this timeframe?

Yes

If no, explain anticipated timeline or barriers to admission:

Is the individual aware of and in agreement with this referral being submitted?

Yes

If No, Please Explain:

Additional Information (Optional) - Please provide any additional information that may assist in reviewing this referral.

We do not maintain a waitlist, but we encourage you to check current openings at: https://www.firstresources.us/hcbsservices

Please send all referral materials, additional documentation, or questions to: irshreferrals@firstresources.us

The First Resources Corp. Intensive Residential Services team is here to partner with you throughout the referral process as we work together to support the individuals we serve.

First Resources Corp. | 710 Gateway Dr., Ottumwa, IA

Phone: 641-682-8114