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Referral Screening Verification Process (RSVP)
The purpose of completing this referral is to initiate a screening or in-reach for TCL. The Transitions to Community Living (TCL) provides eligible adults living with serious mental illnesses the opportunity to choose where they live, work, and play in North Carolina. TCL promotes recovery through providing long-term housing, community-based services, supported employment, and community integration.
See the DOJ settlement for further details
*
Referrer role
Individual seeking services
Guardian
Hospital
LME-MCO
Provider
Standard Plan
Other
*
Standard Plan
AmeriHealth Caritas of North Carolina
Blue Cross and Blue Shield of North Carolina
UnitedHealthcare of North Carolina
WellCare of North Carolina
Carolina Complete Health, Inc
Other role
*
Does the individual being referred have a guardian?
Yes
No
If the individual has a guardian that is considered a “guardian of the person” or “general guardian,” but
not
the “guardian of the estate,” that guardian
must
be notified
before
making the referral.
The individual completing the referral has received consent
from the individual being referred
to contact the LME-MCO for a diversion screening and/or to initiate in-reach.
*
Referrer first name
*
Referrer last name
*
Referrer phone number
Referrer phone number
-
-
ext.
Referrer email address (optional)
Remember me for next time
(do not use on shared/public computers or devices)
*
Individual first name
*
Individual last name
*
Individual date of birth (Example: 5/19/1956)
*
Individual gender
Male
Female
Other
*
Individual phone number
Individual phone number
-
-
ext.
Individual e-mail address (optional)
Location of individual at time of referral
Search for a DHSR licensed facility by name
Manually enter individual's location at time of referral
*
Name of facility, hospital, or shelter (start typing to search)
Type Code
None
Skilled Nursing
Combo ACH and Skilled Nursing
ACH
.5600 Licensed Facility
Hospice Residential Care
State Psychiatric Hospital
Other
Inpatient Psychiatric Facility
Community Hospital
Crisis Bed
Emergency Department
Addictive Disease Inpatient Treatment
*
Bed Type
?
Help
Choose type of bed that individual will be occupying at facility.
[
X
]
ACH bed
Nursing bed
*
Name of facility, hospital, or shelter (if applicable)
*
Individual's location type
ACH
Combo ACH and Skilled Nursing
.5600 licensed facility
Skilled Nursing facility
Community hospital
Homeless (boarding house/hotel/shelter)
Incarcerated
With family/friends (temporarily)
Residing in private residence
*
Bed Type
?
Help
Choose type of bed that individual will be occupying at facility.
[
X
]
ACH bed
Nursing bed
*
Individual's location address
*
City
*
ZIP code
*
State
Select one
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Peurto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Admission Date Required
SPH
CH
ACH
None
*
ACH Admission Date
?
Help
Enter date individual was admitted to ACH or date expected to be admitted to ACH.
[
X
]
*
SPH Admission Date
?
Help
Enter date individual was admitted to State Psychiatric Hospital.
[
X
]
*
Admission Date
*
Reason for referral (select all that apply)
Reason for referral (select all that apply)
Mental health
*
Potential mental health diagnoses (select all that apply)
Bipolar I disorder
Bipolar II disorder
Borderline personality disorder
Delusional disorder
Major depressive disorder
Schizoaffective disorder
Schizophrenia
Paranoid schizophrenia
Post-traumatic stress disorder (PTSD)
Unknown
Substance use
Traumatic brain injury (TBI)
Intellectual/developmental disability
Medical
*
Medical diagnosis
Personal care services (PCS)
*
Is the individual potentially eligible for Medicaid?
Yes
No
Application Pending
Have not applied
Unknown
*
Last four digits of individual's Social Security number
*
Individual's county of residence
LME-MCO:
Add any additional information about the individual that you think is necessary to assist in the screening process (ex: past hospitalizations, medications, history of diagnoses, medical conditions, other insurance coverage, etc.)
*RSVP is not able to accept uploads. Please provide contact email address and telephone so that collateral documentation can be gathered during the upcoming screening process. Please also list the collateral documents that can be provided. (Example: abcd@maryshospital.com, 555-555-1234, Comprehensive Clinical Assessment, Psychological Assessment, Hospital Intake/Discharge? paperwork, etc.)
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TCLD.Support@DHHS.NC.GOV
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