Valley Housing Application Packet Check-List

Please ensure that all of the items below are included in the referral submitted to [email protected]

Referral Sheet
Medicaid/Medicare Verification for Salt Lake County
Income Verification
TB Test Verification
Bank Statements (3 Months)
Copy of Social Security Card
Copy of Current State ID
Copy of Birth Certificate

Patient Name*
Age
DOB*
Phone*
Email
Social Security Number
Address / Current Location
Street Address City State / Province / Region
Currently Homeless?
Phone
Gender
Pronouns
Pending Homeless Date
MM slash DD slash YYYY
Active Optum Medicaid (Traditional only)
Income Amount / Source
Payee
Do you have any felony convictions or pending charges?
Are you required to register on the sex offender registry?
Are you willing to have a roommate?
Have you ever been convicted of a violent crime?
Have you had any meth charges?
Do you have a current lease / contract with a housing agency?
Do you have a past due balance with Valley?
REASON FOR REFERRAL/NEED FOR SUPPORTED HOUSING/CURRENT LIVING SITUATION:
Mental Health
Mental Health DX
Visual Hallucinations
Auditory Hallucinations
Paranoia
Personality DX
Medications
List of Current Medications
What is your current pharmacy?
Is the patient medication complaint?
How frequently are medications missed or forgotten?
Prescribed Clozaril / Clozapine
Prescribed Zyprexia Relprev Injection
General Medical Conditions/ History of:
Heart Problems
Physician
Follow Up needed
Kidney Problems
Dialysis
Physician
Follow Up needed
Lung Problems
Oxygen
Tanks
Concentrator
Frequency
Supplier
Physician
Follow Up needed
Seizure Problems
Last
Fequency
Post seizure period
Physician
Follow Up needed
Diabetes Problems
Independently Managed
Physician
Follow Up needed
Upcoming or recent surgeries
Physician
Follow Up needed
Primary care doctor
Allergies/Dietary Restrictions
Medical concerns may be a barrier to entering residential treatment if:
1. The type or amount of medical monitoring and assistance and treatment that staff is expected to deliver exceeds that of a high school graduate with a CPR card and no medical licensing or training; and/or
2. The time away from the program required for the patient to manage their health care problems substantially interferes with the quality and quantity of care they are supposed to be getting at the residential program.
Total Psychiatric Hospitalizations:
History of Suicide attempts
Last / Method
History of Self harm
Last episode / Method
Prior USH Admissions
Substance Use
Substance Use DX/history/Drug of choice/first use/last use
Prior Out Patient Substance Use Tx (include ASAM level and program)
Prior Residential Substance Use Tx
Which Program(s)
Do you believe you have a substance use problem or addiction?
What are your motivations to engage in and complete treatment at this time?
Court Ordered Treatment
Total Number of Incarcerations (jail or prison)
Probation Officer
Current Charges
Pending Charges
Past Charges
Warrants
Referral
Name
First Last
Email
Phone
Patient Acknowledgment:
Medications: I understand that the medications I am currently taking and or prescribed, may not be approved by my new treatment team and are subject to change upon admission. Examples of medications that are NOT approved for use while in treatment include but are not limited to: Epi-Pens, Benzodiazepines, Amphetamines/Stimulants, Gabapentin, Wellbutrin (bupropion), Soma (carisoprodol), Ambien (zolpidem) and any other opiates/narcotics or controlled substances. I understand that the prescriber may speak with me about other medication alternatives and options. If my medications are not approved, I understand that I will be required to stop taking them prior to admission or shortly thereafter under the care of a Valley prescriber.

Utilizing services: Moving into Valley Behavioral Health’s Supportive Housing Programs, I understand the services offered in housing are provided to best support coordination of my treatment, medical needs, and sobriety needs. Unless I am required to complete Court ordered treatment at Forensics, I acknowledge living into Supportive Housing with Valley includes utilizing the following, according to the unit’s program procedures:

Primary Care Services
Primary Care Coordinator
Case Management
Medication Management
Pharmacological Management
Pharmacy Services
Urinary Analysis

Urinary Analysis:
Reasons the treatment team may request drug testing include:

1.The patient has a substance use disorder and is engaged in treatment to manage that problem.
2. Patient behavior raises suspicion of substance use. Refusal to submit a urine drug test when requested may result in a lease violation.
I acknowledge that I have read and understand the previous statement*
I have read
Consent*
I agree to the privacy policy.
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Valley Housing Application Packet Check-List

Valley Housing Application Packet Check-List

Mental Health

Medications

General Medical Conditions/ History of:

Medical concerns may be a barrier to entering residential treatment if:

Substance Use

Court Ordered Treatment

Referral

Patient Acknowledgment:

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SLC: (888) 949-4864