PB # OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11)
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1 FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office of Procedures POLICY BULLETIN # OPE REVISIONS TO THE REFERRAL TO TREATMENT PROGRAM (M-687r) Date: November 30, 2011 This procedure can now be accessed on the FIAweb. Subtopic(s): Form This policy bulletin is to inform Substance Abuse Service Center (SASC) staff as well as staff of the Comprehensive Services Model (CSM) vendors that the Referral to Treatment Program (M-687r) form has been revised. Form M-687r is to be used by staff of the SASC as well as CSM vendors when referring applicants/participants to substance abuse treatment programs. In addition to updating the logo and formatting to match current agency standards, the M-687r form has undergone the following revisions: Check boxes for Credentialed Alcohol Substance Abuse Counselor (CASAC) either at SASC or at a CSM Vendor to indicate the level of treatment required, either intensive or non-intensive, have been added. The check boxes for New Referral and Already in Program have been relocated to the top of the form. The MTA s information number has been included so that applicants/participants may contact MTA for specific directions to the treatment program. The requirements for the manual reporting of compliance with the treatment program have been removed as this is now completed using the Substance Abuse Tracking and Reporting System (STARS). Note: The M-687r form is designed as a fill and print form available at the FIA Forms page. Once the form is printed, it must be scanned and indexed into the electronic case record. Effective Immediately HAVE QUESTIONS ABOUT THIS PROCEDURE? Call then press 3 at the prompt followed by 1 or send an to FIA Call Center Fax or fax to: (917) Distribution: X
2 PB # OPE Attachment: Please use Print on M-687r Referral to Treatment Program () Demand to obtain copies of forms. M-687r (S) Referral to Treatment Program (Spanish) () FIA Policy, Procedures, and Training 2 Office of Procedures
3 Form M-687r (page 1) LLF Date: Case Number: Case Name: Program Code: Referral to Treatment Program Please check one: New Referral Already in Program Please check one: Intensive Tx Required Non-intensive Tx Required Section I: Applicant/Participant Information(to be completed by referring Worker) First Name M. I. Last Name Suffix Number: Line Number Section II: Instructions to Applicant/Participant You are being referred to a drug/alcohol program for treatment to help you become employable. You must report to the program with this Referral form and your signed Consent for Disclosure form. You must report to this mandatory appointment on time. You cannot change this appointment unless you have a legal or medical emergency, which must be documented. If you are unable to keep this appointment, you must call: before the scheduled appointment date. Appointment Date: Treatment Program: Time: Telephone: Address: City: State: Zip Code: For travel directions please contact the MTA at (718) As a cash assistance Applicant/Participant with a substance abuse problem, I understand that I must comply with the requirements of both HRA and the Treatment Program. I understand that failure to report to or comply with the above mandated appointment may jeopardize my eligibility for or continued receipt of cash assistance, food stamps, and medical assistance benefits. Applicant/Participant Signature Date Worker Name (print) Date Telephone Number (See Reverse)
4 Form M-687r (page 2) LLF Human Resources Administration Family Independence Administration Section III: To Treatment Program Referral outcome information must be reported in the Substance Abuse Tracking and Reporting System (STARS) within two business days of applicant/participant's appointment date. Please refer back to the location on top of the form, on the next day, clients who were given an inappropriate referral. Inappropriate Referral - Applicant/Participant must report back to the referring site on (Enter referral recommendation below, including service type and, if applicable, specific programs.) (Next Business Day) Preparer Name (print) Preparer Signature Title (print) Date Telephone Number
5 Form M-687r (S) (page 1) LLF Fecha: Número de Caso: Nombre del Caso: Código del Programa: Envío a Programa de Tratamiento Favor de marcar una casilla: gfedc Nuevo Envío gfedc Ya en el Programa Favor de marcar una casilla: gfedc Se Requiere Tx Intensivo gfedc Se Requiere Tx No Intensivo Sección I: Información del Solicitante/Participante (a ser llenada por el Trabajador que corresponda) Nombre I. Apellido Número de Sufijo: Número de la Línea Sección II: Instrucciones al Solicitante/Participante Usted está siendo enviado(a) a un programa de tratamiento para drogas/alcohol para ayudarle a poder trabajar. Debe presentarse al programa con este formulario de Envío y el formulario firmado de Autorización para Revelar Información. Debe presentarse a esta cita obligatoria a tiempo. Usted no puede cambiar esta cita a menos que tenga una emergencia legal o médica, la cual debe ser documentada. Si no puede cumplir esta cita, debe llamar a: antes de la fecha de la cita programada. Fecha de la Cita: Programa de Tratamiento: Hora: Teléfono: Dirección: Ciudad: Estado: Código Postal: Para indicaciones de viaje favor de comunicarse con la MTA al (718) Como Solicitante/Participante del programa de asistencia en efectivo con un problema de adicción a drogas, entiendo que debo cumplir con los requisitos ambos, de la HRA y del Programa de Tratamiento. Entiendo que si no cumplo o no me presento a la cita obligatoria mencionada arriba, podría poner en peligro mi elegibilidad para asistencia en efectivo, cupones para alimentos, y beneficios de asistencia médica. Firma del Participante/Solicitante Fecha Nombre del Trabajador (letra legible) Fecha Número de Teléfono (Vea al Reverso)
6 Form M-687r (S) (page 2) LLF Human Resources Administration Family Independence Administration Section III: To Treatment Program Referral outcome information must be reported in the Substance Abuse Tracking and Reporting System (STARS) within two business days of applicant/participant's appointment date. Please refer back to the location on top of the form, on the next day, clients who were given an inappropriate referral. gfedc Inappropriate Referral - Applicant/Participant must report back to the referring site on (Enter referral recommendation below, including service type and, if applicable, specific programs.) (Next Business Day) Preparer Name (print) Preparer Signature Title (print) Date Telephone Number Nombre del Empleado del Programa (con letra legible) Firma del Empleado del Programa Título (letra legible) Fecha Número de Teléfono
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