Professional Referral

Submit a Referral

For hospitals, psychiatric facilities, nursing facilities, Tailored Care Managers, guardians, ACT/CST teams, outpatient providers, DSS/benefits teams, and other authorized referral partners.

Submit only after obtaining valid authorization to share the individual's information or confirming legal authority to release it. A referral is a request for review; it is not an admission, bed hold, or funding guarantee.

Your Referral ID

Keep this number for any additional documents you send for this referral.

Leave blank

Step 1 of 8

Referral Source

Person completing referral *

Organization *

Role / title

Phone *

Email *

Referral date

I confirm that valid authorization/legal authority permits this referral and transmission of supporting information.

Step 2 of 8

Resident Identity & Current Setting

Full legal name *

Preferred name

Date of birth *

Current location / facility *

Current county

Proposed transition date

Reason residential placement is being requested *

Step 3 of 8

Care Team & Legal Contacts

Guardian / LRP name

Guardian / LRP phone/email

Tailored Care Manager / Care Coordinator

TCM organization

Psychiatric provider

Primary care provider

Representative payee

Other key team member

Step 4 of 8

Clinical & Placement Fit

Primary mental-health diagnosis *

Secondary psychiatric / medical / cognitive diagnoses

Current psychiatric stability

Medication adherence concerns?

Recent physical aggression?

Elopement / wandering risk?

Behavioral history, triggers, de-escalation strategies, safety concerns, or legal/supervision conditions

ADL/IADL, mobility, medical, dietary, or other functional support needs

Step 5 of 8

Funding, Medicaid & 1915(i)

Medicaid status

Medicaid ID

Tailored Plan / LME-MCO

1915(i) eligibility/status

ISP end date

Reassessment target date

Special Assistance status

Other benefits

Current or anticipated service authorizations / wrap services

Step 6 of 8

Required Supporting Packet

You may attach supporting records below. If you have additional records, submit them separately through Secure Document Upload using this referral's Referral ID.

Psychiatric evaluation / CCA

Medication list / MAR

Discharge summary / transition plan

Recent progress / behavioral notes

Insurance / benefits documentation

Guardianship / legal documentation

Selected files: 0.00 MB total

Step 7 of 8

Referral Readiness & Missing Items

Records not yet available / expected later

Who owns follow-up for missing items?

Expected date remaining records will be available

I understand that referral submission, a tour, benefit approval, or payer authorization does not guarantee admission or reserve a bed.

Step 8 of 8

Submit for Review

APTCH will conduct clinical, administrative, safety, funding, compatibility, and capacity review. Do not discharge or transport the prospective resident for move-in until APTCH issues written acceptance and move-in confirmation.

Additional information