DELAWARE DEPARTMENT OF HEALTH AND SOCIAL SERVICES 
DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 
DSAMH BEHAVIORAL HEALTH INTENSIVE SERVICE SYSTEM 


ELIGIBILITY DETERMINATION REVIEW 


ENROLLMENT APPLICATION FORM


DSAMH ELIGIBILITY AND ENROLLMENT UNIT
Ken Donovan, Director 
14 Central Ave. 
New Castle, DE 19720 


302/255-9453 (voice) 
302/255-4448 (fax) 
Ken.Donovan@state.de.us 


Last Reviewed on February 28, 2006 


I. 
DEMOGRAPHIC 
AND 
BACKGROUND 
INFORMATION 
1. 
Applicant’s Name: 
(Last) (First) (M.I.) 
2. 
Date of Application: ____/_____/_____ 
3. 
Applicant Date of Birth: ____/____/____ Gender ___M ___F 
4. 
SS#_________________ 
5. 
Source and amount of income_____________________________________ 
5. 
Medicaid #: Medicare #______________________ 
Other insurance (specify) _____________________________________ 
6. 
Current Residence (type) ______________________________________________ 
Indicate whether the applicant lives in a private residence, psychiatric inpatient facility (provide 
name) or jail/prison (provide name), supervised residence, AMID housing. 

7. 
Current Street Address: 
City: State: Zip Code: 
Home Phone: Work Phone: 


8. 
Person to Contact in Case of an Emergency__________________________________ 
Address ______________________________________________________________ 
Phone Number _______________ Relationship ____________________________ 
9.
. 
Primary Language [ ] English [ ] Spanish [ ] American Sign Language [ ] Other 

10. Race 
[ ] American Indian/Alaskan Native [ ] AA plus other race/s [ ] Black/African American 
[ ] BL plus other race/s [ ] White/Caucasian [ ] CA plus other race/s 
[ ] HA plus other race/s [ ] Native Hawaiian/other Pacific Islander 
[ ] Multiracial Unspecified [ ] Asian [ ] Asian plus other race/s [ ] Unknown 
11. Ethnicity 
[ ] Puerto Rican [ ] Mexican [ ] Cuban [ ] Other Hispanic [ ] Not of Hispanic Origin 
[ ] Unknown 
12. Name of Employee Submitting the Application: 
(Print name) 
Title: ____________________________ Credentials______________________
_ 
Signature: 
Organization:
Address: 


 Phone # Fax # __________________________ 
Last Reviewed on February 28, 2006 


13. Current Treatment Provider(s): 
Community Psychiatrist/Therapist notified of application for services YES ____ NO ___
_ 
Do they agree with client’s need for intensive services? YES____ NO___
_ 
Phone # _______________________ Fax # _________________________
_ 


14. Other agencies working with client____________________________________________ 
15. Family Physician (primary care provider) _______________________________ 
Phone # _________________ 
16. For Child Mental Health referrals, include the following information: 
a. 
Family contact Name ____________________________________________
_ 
Address _______________________________________________________
_ 
City __________________ State______________Zip Code _____________
_ 
Telephone ____________________________________
_ 
b. 
Proposed Living Arrangement at age 18________________________________ 
c. 
DCMHS Coordinator _______________________________________________
_ 
Phone Number___________________________
_ 
17. 
Recommended level of care: _______CCCP _______Group Home _______Cornerstone Res. 
Copy of the appropriate release of information form for purposes of enrollment 
application (revised 1/12/2006) must be signed and dated by client and attached 
to this form. 

Last Reviewed on February 28, 2006 


II. 
DIAGNOSIS 
A. 
PSYCHIATRIC DIAGNOSIS (DSM-IV-TR) 
Diagnosis must have been rendered within the past 12 months. 
A copy of the most recent psychiatric evaluation must accompany this application. 

For Axes I & II, indicate primary and secondary diagnosis and the justification for the diagnosis 

Axis I: Clinical Disorder Check One (Axis I or II) to indicate PRIMARY DIAGNOSIS 
Code _____________ [ ] _____________________________________________ 
Code: ____________ [ ] _____________________________________________ 
Code: ____________ [ ] _____________________________________________ 

Please describe the clinical symptoms and conditions that justify the diagnosis indicated. 

Axis II: 
Personality Disorders/Mental Retardation 

Code _____________ [ ] _____________________________________________ 
Code: ____________ [ ] _____________________________________________ 
Code: ____________ [ ] _____________________________________________ 

Please describe the clinical symptoms and conditions that justify the diagnosis indicated. 

Axis III: General Medical Conditions (ICD-9-CM name) Use additional space if needed. 

Code: ____________ ____________________________________________ 
Code: ____________ ____________________________________________ 
Code _____________ ____________________________________________ 
Code: ____________ ____________________________________________ 
Code: ____________ ____________________________________________ 

Please describe the clinical symptoms and conditions that justify the diagnosis indicated. 

Last Reviewed on February 28, 2006 


Axis IV: Psychosocial and Environmental Problems (Check and Describe): 

( ) Problems with primary support group (specify) 

( ) Problems related to the social environment (specify) 

( ) Educational problems (specify and indicate the highest grade completed) 

( ) Occupational problems (specify) 

( ) Housing problems (specify) 

( ) Economic problems/ management of funds (specify) 
( ) Problems with access to health care (specify) 

( ) Problems related to interaction with the legal system (specify all previous charges, convictions and 
probationary status) 

( ) Other psychosocial and environmental problems (specify) 

Axis V: Global Assessment of Functioning Scale: 
Current: Highest level in the past year: 


Diagnostician: Psychiatrist who performed the evaluation and formulated the diagnosis: 

(Print Name) 
Phone # Date of Diagnosis: 
Signature: 

Currency of Diagnosis: Currency of diagnosis: Diagnosis was rendered within the (check one): 
Past Week _____ Past Month _____ Past 90 days ______ Past 180 days ______ 

Last Reviewed on February 28, 2006 


Substance Abuse Rule Out 

Has a substance abuse diagnosis been specifically ruled out as either a primary or secondary diagnosis? 
Yes No 

If yes, please indicate the basis for the rule out: 

If a substance abuse diagnosis has not been ruled out, a recent Addiction Severity Index (ASI) including 
the ASAM summary completed or updated by a clinician must be attached to this form. “Recent” is 
defined as having been completed within the past 90 days. If a substance abuse diagnosis has been 
ruled, please indicate the basis for this: 

III. 
FUNCTIONAL 
IMPAIRMENT 
A. Provide a brief description of the applicant’s history with their psychiatric and addictive 
disorders, including the individual’s symptoms, treatment, treatment response and attitude about 
treatment, emphasizing factors that have contributed to—or inhibited—previous recovery efforts. 
1. Mental Illness: 
2. Substance Abuse (reference ASI findings): 
3. If the applicant has a co-occurring disorder, describe the interaction between Mental Illness and 
Substance Abuse: 
B. Describe the functional impairments that have resulted from the applicant’s mental illness 
and/or substance abuse, including their current manifestation in the following functional domains. 
Indicate the duration of the impairment, if known to the writer, and reference the Axis IV and Axis 
V findings from Section I: 
1.Self-Care: 

Duration: Current:__ Recent (within 6 mon.):__ Long Term (6 mon.+):__ Unknown:__ 

Last Reviewed on February 28, 2006 


2. Suicidality (distinguish among passive thoughts of being better off dead, ideation with and 
without a plan, recent attempts, past history of attempts and current potential; provide specific 
details on the seriousness of attempts): 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

3. Self Controlrol /Impulsivity: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

4. Dangerousness (distinguish among dangerousness to self, others and property): 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 
5. Caused Community Complaints (bizarre or unusual behaviors) ______________ 
____________________________________________________________________ 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

6. Illness Management: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

7. Emotional Health: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

8. Interpersonal/Social Functioning: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

9. Cognition/Learning: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

10. Motivation/Coping: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

Last Reviewed on February 28, 2006 


11. Substance Abuse: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

12. Physical Health: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

13. Recovery/Relapse Prevention: 
Duration: Current:__ Recent (within 6 mon):__ Long Term (6 mon.+):__ Unknown:__ 

IV. 
SUBSTANTIAL 
INTERFERENCE 
WITH 
OR 
LIMITATION
INMAJORLIFEACTIVITIES
A. Describe the impact of the applicant’s current functional impairments on all affected major life 
activities: 
1. Employment: 
2. Education: 
3. Family Relationship: 
4. Social Relationships: 
5. Independent Living: 
V. 
HISTORY 
OF 
INTENSIVE 
BEHAVIORAL 
HEALTH 
TREATMENT 
A. Onset of illness and treatment initiation 
Unknown 
1. Date of first onset of mental illness ____/____/____ 
2. Date of first treatment for mental illness ____/____/____ 
3. Date of first onset of substance dependence ____/____/____ 
4. Date of first treatment for substance dependence ____/____/____ 

Last Reviewed on February 28, 2006 


B. Treatment Service history. Include all inpatient and outpatient treatment. We are particularly 
interested in the past 24 months. If more space is needed, attach additional page(s). 
DATES PROVIDER and SERVICE TYPE 
FROM TO 

C. Describe previous Intensive Case Management (CTT/CCCP) or Group Home placements. 
Indicate client’s response to this level of treatment and any specific problems encountered. 
D. Please list and describe any medications with known adverse drug reactions and /or lack of 
responsiveness for this client. 
Medication Describe adverse reaction /lack of responsiveness 

Last Reviewed on February 28, 2006 


E. Please list all current medications and dosages. You may attach a copy of your MAR or order 
sheet if it is legible. 
Medication Dosage 

1. 
2. 
3. 
4. 
5. 
F. Attach any laboratory tests results, including tests for therapeutic drug levels, alcohol/drug 
screens, Complete Blood Count (CBC), Complete Metabolic Profile (CMP), Thyroid Stimulating 
Hormone (TSH) and any other diagnostic studies. 
VI. 
SUMMARY 
A. Evaluate the treatment and medication regimens used with the applicant during the last year, 
indicating reasons for the lack of effectiveness of the treatment plan and/or service delivery. 
B. Based on the individual’s functional impairments and their effect on major life activities, 
describe the reasons why traditional out patient treatment cannot meet the applicant’s needs and 
why the applicant requires CCCP Intensive services or Residential Treatment/Support. 
C. Has a LOCUS assessment been completed on this client? ______YES ______NO 
If yes, please attach. 

Last Reviewed on February 28, 2006 


STATE OF DELAWARE 

DEPARTMENT OF HEALTH AND SOCIAL SERVICES 

DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION 

In compliance with Federal Regulations (42 U.S.C. 4582 and 21 U.S.C. 1175) and the Health Insurance Portability 
and Accountability Act (HIPAA) of 1996 (45 C.F.R. Pts. 160 and 164) 

Client Name: _________________________________DOB: _____________ 
SS#: _____________________ 

I, the undersigned, hereby authorize the Eligibility & Enrollment Unit to disclose to the following entities: 

• 
Brandywine Counseling, Inc. 
• 
Brandywine Hills (RHD) 
• 
Connections CSP. (CCCP/Meadows Res./Blackbird Group Home) 
• 
Delaware Psychiatric Center 
• 
Division of Vocational Rehabilitation 
• 
Fellowship Health Resources (CCCP,Georgetown Group Home/ Hope House Group Home/ Taton Group Home) 
• 
Gateway Foundation 
• 
Gaudenzia 
• 
Horizon House (CCCP/ Bennett House/ Wilson House/ Old Balt. Pike) 
• 
Limen House 
• 
Now Group Home (RHD) 
• 
Psychotherapeutic Services, Inc. (CCCP, Felton Group Home) 
• 
Other: 
the following information: the Eligibility & Enrollment Application Packet, ASI, Assessment Summary, ASAM 
Summary, Consumer Reporting Forms (pages 1 & 2), Eligibility & Enrollment Summary Sheet and the 

S.E.T. Service Authorization Form. 
The purpose or need for this disclosure is to coordinate behavioral health care treatment. 

I understand that my records are protected under federal regulations governing Confidentiality of Alcohol 
and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability 
Act of 1996 ("HIPAA"), 45 C.F.R. Pts. 160 and 164 and cannot be disclosed without my written consent 
unless otherwise provided for in the regulations. I also understand that I may revoke this consent in 
writing at any time except to the extent that action has been taken in reliance on it. I understand that my 
private health information, once disclosed to others, may be redisclosed to individuals or organizations 
not subject to HIPAA and may no longer be protected by HIPAA. I understand that generally DSAMH 
may not condition my treatment on whether I sign an authorization form, but that in certain limited 
circumstances I may be denied treatment if I do not sign an authorization form. 

This consent extends from this date until 60 days post discharge from DSAMH/Contracted services. 

Signed___ ________________________________ Date _______________ 

(Relationship if signed by other than client) 

Last Reviewed on February 28, 2006