Intake & Navigation Form

NOTE TO STAFF: Please welcome the family, introduce yourself and then explain the intake process. (You might have already done some of this when you SCHEDULED the intake.)

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I'm a Family Support Specialist. After today's conversation, I can schedule appointments with any of our contracted therapists and I can also connect you with other resources and supports that your family might need. 

RCCMHC has 17 staff. For now, I will be your main contact but each of us have different specialties so we work as a team to support your family. You will also have a Family Coach. A Family Coach is a parent who has personal experience with youth mental health. Your Family Coach will be (Jacinta/Connie.) You can also choose to bring other people onto your Care Team (school, county, therapist, family service agency etc.) 

(If you are on Zoom, you can explain why there are sailboats on this form. "Pretend we are two people in a sailboat. You will tell me where you want to go and I will help you get there. Some people call this resource navigation.") 

I'll be using a Navigation Tool to guide our discussion. It can take approximately one hour. You don't have to answer every question. If something is not important to you, we can skip it. 

1. First, I will ask you some basic questions about your family. 
2. Then I will ask you a few eligibility questions and I will ask for your verbal consent to provide services. 
3. The next part is a Youth Screening. I will ask you to describe what's going on with your child and I will ask you some deeper questions about things like: emotions, behavior, thinking, school concerns, and current services. We will also talk about what mental health services you would like for your child. 
4. The last part of our conversation is a Family Screening. I'll ask you questions about your whole family so we can connect you with supports for things like: adult mental health, housing, financial supports or family programs.

Some families like to have 2 meetings- one for the Youth Screening and one for the Family Screening. You can decide today while we are talking. 

The last thing I will do is ask for your insurance information (if you have it) and I will ask you to sign a release of information.

After our meeting is over, I will send you a list of free CALM Toolkit supplies. You can choose which ones you would like to be delivered to your home. Then, within 1-2 business days, your Family Coaches will reach out to you to help you place your order and tell you about a few more of our free services. 

NOTE TO STAFF: Before proceeding with the intake, make sure to ask if there is an emergency, crisis or urgent safety concern for anyone in the home.

If the caregiver answers YES (or, I'm not sure): Click here to access the Triage Form.  After assessing the potential emergency/crisis situation, you might return to the intake form.  If not, please schedule a follow-up appointment with the parent/caregiver to complete the intake paperwork.

NOTE TO STAFF: Please explain to parents/caregivers that if they answer no to any of the above questions, their family is not eligible to receive services from RCCMHC.  Please let them know you will consult with your supervisor and we will follow up with the family within two business days to provide other options.

NOTE TO STAFF: Please introduce the parent/caregiver to our 1-800 Resource Line and help them to save the number in their cell phone contacts. (800-565-2575)

Ramsey County Children's Mental Health Collaborative Services, Terms, Conditions & Consent

DON'T GET CONFUSED BY OUR NAME! Ramsey County just describes where we work. None of our staff are county employees. Most people just call us "the collab" or their "collab family."

All of our services are FREE and voluntary. 

• Resource navigation 
• Therapy appointment setting and referrals
• Care Team Coordination (school, county, primary care, local healers and providers)
• Peer support and resilience coaching
• Classes and programs (adults)
• Moodie Mondays (skills groups for kids/teens)
• Resource events- "one stop shopping"
• CALM Toolkit supplies and Family Care Organizer etc

HEALING, BELONGING, AND HOPE: Most of our staff have lived experience with mental health, trauma, and/or poverty. We will support you without judgement. We will work hard to earn your trust so that we can partner together. If there is anything that we can do to make you feel welcome, please let us know. It's ok to miss a meeting or training- we understand that life happens. You can stay with RCCMHC as long as you'd like.

FREE TOOLS AND SUPPLIES: Throughout the year, we will help you build your family's CALM Toolkit with items you have at home and items that we give away at programs and classes. As a new family with RCCMHC, you can select some free CALM Toolkit supplies right away!  After your intake, we will send you a long list of choices. Then, one of our Family Coaches will reach out to confirm delivery to your home. You can also request a Family Care Organizer.

PROGRAMS AND EVENTS: To receive a giftcard or CALM Toolkit supplies, you must be present for the full event. Giftcards are delivered through email or text message. Supplies are delivered to your home (for example; by Amazon.) 

• 101 Trainings- $20 giftcard for 2 adults per family.
• 2.0 and Wellness Programs- CALM Toolkit supplies per family
• Moodie Mondays for youth-  CALM Toolkit supplies, giftcards or pizza :) 
• Family Service Committee- $20 per adult
• Resource Fairs and Surveys- raffle prizes 
• Special Programs: CALM Toolkit supplies

INFORMATION SHARING & MANDATED REPORTING: RCCMHC will not share your information without your permission. If you need us to share information, you will sign a form called a Release of Information. This form will tell us who you want to be part of your Care Team (for example: the School or County or a local Family Service Agency. The only time that we might need to talk to someone without your signed Release of Information is if we think you or your child are in danger or if you say that you or your child are planning to hurt yourself or someone else. If that happens, we will do our best to get you help right away. This means that RCCMHC staff might have to consult their supervisor or connect you with emergency supports.

PHONE CALLS and TEXT MESSAGES: We offer phone and text message services related to the programs above. If you opt in for this service. Message and data rates may apply. To stop getting text messages from us, you must reply STOP.

NOTE TO STAFF: If you have not already done so, start by asking about emergency or crisis concerns. 

If the caregiver answers YES (or, I'm not sure):

1. First, save the information in this form by clicking SUBMIT.
2. Next, open our RCCMHC Portal and use the Triage Form.

Please reassure the caregiver that you can resume the intake/resource navigation after the emergency or crisis is resolved. 

NOTE TO STAFF: provide these reminders as you get started. 

CAREGIVER-GUIDED: "Remember, you are guiding the disussion. It's okay to skip a question or answer it at a later time."

PRIVACY AND SAFETY DURING MEETINGS: "Your child or another adult might be nearby while you are talking to us. If you don't feel comfortable or safe talking about a particular topic, just let us know. If you need more privacy and can't talk out loud... we can talk about resources through CHAT over zoom, through email or over our texting line. We could also set up a time to meet you in the community (like, at a library.)"

NOTE TO STAFF:  You may want to pause here and ask the parent/caregiver to tell you a little bit about their child (or, why they were referred.)  After listening and taking notes, you can continue with questions below.

You may want to take written notes in a notebook and then add them to this section after the intake. 

NOTE TO STAFF: Different people and cultures have different ways of talking about mental health experiences. Some families may have strong stigma associated with mental health disorders. Some languages may not have words that translate as "mental health", "depression" or "anxiety" etc. 

• Remember to LISTEN and ask questions
• Try asking about "sadness" or "stress" instead of asking about "depression". 
• Ask about physical symptoms (tightness in chest, headache, stomachache) instead of asking about "anxiety." 

As you are listening, you may notice that a parent/caregiver is describing mental health or safety danger signs- even if they previously stated that there was not a crisis or emergency situation. If this happens- ask to PAUSE and consult the Triage Form. 

• For example- "I just heard you say that your child has been talking about wanting to die. That's a danger sign that can quickly lead to an emergency. I'd like to pause for a moment so I can ask you some follow up questions. If needed, we can get you faster supports without having to complete the full intake today."

So far, we discussed what services are already in place for your child/teen.

Are you interested in any other referrals or resource connections for your child/teen?  RCCMHC can help make referrals and resource connections.  

NOTE TO STAFF: At this point in the screening, if you think that a THERAPY referral may be the best service path, please complete the chart below. Please only select the caregiver's top three "important factors" and enter any comments from the parent/caregiver. 

NOTE TO STAFF: If you think this family may need a Rapid Access appointment, you could open your Family Support calendar in a new window and select the appointment right now. Or, you can list the family's availabilty below and then follow up with them ASAP.

NOTE TO STAFF: If you have not already done so, start by asking about emergency or crisis concerns. 

If the caregiver answers YES (or, I'm not sure):

1. First, save the information in this form by clicking SUBMIT.
2. Next, open our RCCMHC Portal and use the Triage Form.

Please reassure the caregiver that you can resume the intake/resource navigation after the emergency or crisis is resolved. 

NOTE TO STAFF:The parent/caregiver is guiding the disussion.  Gently remind them it is okay to skip a question or answer it at a later time.  

NOTE TO STAFF: Different people and cultures have different ways of talking about mental health experiences. Some families may have strong stigma associated with mental health disorders. Some languages may not have words that translate as "mental health", "depression" or "anxiety" etc. 

• Remember to LISTEN and ask questions
• Try asking about "sadness" or "stress" instead of asking about "depression". 
• Ask about physical symptoms (tightness in chest, headache, stomachache) instead of asking about "anxiety." 

RCCMHC can help make referrals and resource connections.  So far, we discussed what services are already in place for your child/teen.

Are you interested in any other referrals or resource connections for your child/teen?

NOTE TO STAFF: At this point in the screening, if you think that a SLMH referral may be the best service path, please complete the chart below. Please only select the caregiver's top three "important factors" and enter any comments from the parent/caregiver. Remember to follow up with your supervisor to confirm the referral and/or appointment. 

NOTE TO STAFF: If you think this family may need a Rapid Access appointment, you could open your Family Support calendar in a new window and select the appointment right now. Or, you can list the family's availabilty below and then follow up with them ASAP.

NOTE TO STAFF: If you have not already done so, start by asking about emergency or crisis concerns. 

If the caregiver answers YES (or, I'm not sure):

1. First, save the information in this form by clicking SUBMIT.
2. Next, open our RCCMHC Portal and use the Triage Form.

Please reassure the caregiver that you can resume the intake/resource navigation after the emergency or crisis is resolved. 

NOTE TO STAFF:The parent/caregiver is guiding the disussion.  Gently remind them it is okay to skip a question or answer it at a later time.  

NOTE TO STAFF: Different people and cultures have different ways of talking about mental health experiences. Some families may have strong stigma associated with mental health disorders. Some languages may not have words that translate as "mental health", "depression" or "anxiety" etc. 

• Remember to LISTEN and ask questions
• Try asking about "sadness" or "stress" instead of asking about "depression". 
• Ask about physical symptoms (tightness in chest, headache, stomachache) instead of asking about "anxiety." 

RCCMHC can help make referrals and resource connections.  So far, we discussed what services are already in place for your child/teen.

Are you interested in any other referrals or resource connections for your child/teen?

NOTE TO STAFF:  If you think this family may need a Rapid Access appointment, you could open your Family Support calendar in a new window and select the appointment right now. Or, you can list the family's availabilty below and then follow up with them ASAP. 

NOTE TO STAFF:  If you think this family may need a Rapid Access appointment, you could open your Family Support calendar in a new window and select the appointment right now. Or, you can list the family's availabilty below and then follow up with them ASAP. 

NOTE TO STAFF:

If the intake/youth screening is taking a long time, you may want to schedule another meeting to do the Family Screening.

However, if there is enough time to do SOME of the screening, there are TWO sections that may be helpful for a therapist. They are starred below (***)

Always ask about urgent family concerns before going any further. If the caregiver says they have an urgent family concern, describe it in the box below. Urgent concerns are TIME SENSITIVE, so you should focus on the urgent concerns and come back to the other questions later. 

ASK PARENTS/CAREGIVERS: Is your family currently experiencing an urgent safety concern (such as domestic violence) or do you require urgent supports for basic needs (such as we don't have a safe place to sleep tonight)?

(***) This section asks about RECENT stressful situations or changes within the household. This can help a therapist better evaluate a child's emotions or behaviors and offer coping strategies.

(***) These questions about Family Support, Family Journey, and Family Togetherness can help providers see your whole child/family-- not just the mental health challenges or concerns. The stories can also help the therapist engage with a child/teen and make a better connection. 

Who is your support system? Think about the people you can count on. It can include family, friends, neighbors, mentors, etc.  (If you do NOT have a support system, we can write that down.)

NOTE TO STAFF:  If a parent/caregiver says they have NO support system...

Validate how lonely/isolating it can feel without a support system. 

• Our families who are struggling with complex needs and youth mental health tell us it is very common to lose friends/family or "burn bridges" with past support systems.
• It can be hurtful when family/friends don't understand what our child or family is going through. 

Offer hope, healing and belonging 

• RCCMHC offers care team coordination, resilience coaching, and peer connections to help you build up your support system. 
• Our staff and families have lived experience- we won't judge and we won't give up on you. 

What is something your family does together/ for fun? What would be considered a 'good day' for your family?

Tell me something about your family's journey. What is unique about your family's experience?

IDEAS:

• Culture, faith
• A treasured memory that make you smile 
• A family tradition
• A unique life experience
• A special holiday memory
• Family wisdom or a saying that is often repeated
• Stories passed down

NOTE TO STAFF:  If needed, you can stop here and skip to the DETAILS page. 

But first... this might be a good time to PAUSE and BREATHE.  

Talking about our worries and stress can take a lot out of us and this has been a long intake and screening. 

Shut your eyes if it helps. Relax your shoulders. Roll your neck. Unclench your jaw. Open your hands and shake them a bit. Place one hand on your chest and another on your belly. Breathe in and out. Breathe in and out. 

You're part of our collaborative family now. Remember that you can reach out to anyone on our team just by texting us. We're here for you!

NOTE TO STAFF: Please do your best to help the parent/guardian fill out the Authorization to Exchange and Disclose Information while you are still on the phone or Zoom meeting together. In particular, help the family to understand what a Care Team is. 

Care Team

Parents/guardians may need RCCMHC staff to help them talk to or coordinate with other systems (School, County, local Family Servcie Agencies etc.) We will always coordinate WITH the family ("nothing about us without us.") For example- if the child is struggling at school, we might email the school and copy the parent/guardian to host a Care Team meeting. If appropriate, we could also include the child's therapist or homelessness prevention specialist. We can help the Care Team come up with a shared plan and a way to communicate with each other. 

The parent/guardian uses this form to select Care Team members and give us permission to talk to and coordinate with them. The paren/guardian can change the list of care Team members at any time. 

RCCMHC offers free family supports and we can also make referrals and resource connections in the community.

NOTE TO STAFF: You can end your meeting here and click SUBMIT. Or, you can go to the next page to gather details on Health Insurance, Release of Information etc. 

Before we make any referrals, we need to know what type of health insurance plan your family is on. This information is often needed when referring for mental health services, such as individual/family therapy, psychiatry, etc.

Whenever possible, please upload a photo of the front and back of the insurance card to the Jotform Navigation Table. 

(see sample below.)

Agree On Next Steps

Today, I will type up our notes and consult with my supervisor if-needed. Then I will email you a list of our next steps.

1. Rapid Access appointment
2. Therapy referral 
3. Resource connection

In my email, I will include a link to your free CALM Toolkit supplies. Your Family Coach (Jacinta/Connie) will reach out to you within 1-2 business days to help you place your order. 

I will also include my email and phone extension and our 800# so you can call or text us anytime. 

I will copy your referring provider if you gave us permission to do so.

_______________________________

NOTE TO STAFF:  if a parent does not have an email, please send the "next steps" information via text message instead. But remember that you will still have to send a "next steps" email to the referring provider.

You can end your intake here.

The notes on page 9 should be completed AFTER the intake.  

REMEMBER: if you are adding notes on this page, you must click on the green SUBMIT button or your work will not save.

Use this note section to track important notes relevant to setting up direct services (intake, appointment setting, care coordination or peer support.) 

After the direct servcie is established, you can track most of your case notes in One Note.

You can add to these notes as often as needed. Just click on the + sign to add a new note.

• Date (Your Name) Details