The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

uy9YTG5922LKwc9gGtv32LJDEvFvfQk8HQBeFzSqQodYmNGeccY7EmHx53rJTsvXtYewyuya5tYDoTU8QpeTnvokTgXmDSepTDnTovMhiDEfDsqxa4nr

UNM Intensive Case Management (ICM) Referral Form

Please answer the questions below to determine if you are eligible for our program.

Once you complete the questions, a response will autopopulate with your eligiblity.

Today's date

M-D-Y

Has using drugs or alcohol interfered with the client's daily life activities, or relationships?

* must provide value

Yes

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Have you been diagnosed with a mental health condition?

* must provide value

Yes

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0 Times

1 Time

2+Times

Been to the Emergency Room or have been hospitalized?

* must provide value

reset

Been to Emergency Psychiatric Services?

* must provide value

reset

Been to any detox services?

* must provide value

reset

Been placed in a detention center psychiatric unit?

* must provide value

reset

In the past 2 years, how many times have you had encounters with law enforcement, including arrests and incarceration?

* must provide value

0 Times

1 Time

2+ Times

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Are you currently in an outpatient mental health or substance use treatment program?

* must provide value

Yes

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Within the last 30 days, have you been discharged from an inpatient mental health or substance use treatment program?

* must provide value

Yes

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Sum of answers 1+2

View equation

Sum of answers 3+4

View equation

Referring agency:

MDC

LOPD

Metro Court

District Court

Probation Parole

Fathers Building Futures

New Awakening

NMCEH

First Nations

Casa de Salud

Albuquerque Community Safety

UNMH-Transition Planning Team

Other

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MDC (100) number

Name of person completing the referral:

Phone # of person completing the referral:

Email of person completing the referral:

Client's First Name:

* must provide value

Client's Last Name:

* must provide value

Alias and or nick names known by

Phone Number:

* must provide value

Name of Alternate Person:

Alternate Phone Number:

Date of Birth:

M-D-Y

Is client currently incarcerated?

Yes

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Expected release date:

M-D-Y

Will the client be on probation upon release?

Yes

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Do you have a support system in the community (ie: family, friends, counselor, etc?)

Yes

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Drug of choice

Are you experiencing homelessness?

Yes

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Do you have an address where you can receive mail?

Yes

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Address:

What areas of town do you hang out?

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Does client currently receive case management services in the community?

Yes

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Where?

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Is the client Hispanic, Latino/a, or of Spanish origin?

Yes

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What is the client's race?

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Black or African American

White

Asian

Hispanic

Multiracial

Other

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To which gender identity does the client most identify?

Female

Male

Transgender Female

Transgender Male

Gender Variant/Non-Conforming

Prefer not to answer

Other

reset

Additional Information:

Expand

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

UNM Intensive Case Management (ICM) Referral Form

Client Qualification

Client Information

Demographics

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