Intake & Navigation Form

NOTE TO STAFF:  On this page, you will...

1. Start your intake by introducing yourself and confirming the parent/guardian's name.
2. Make sure that you both speak the same language. If needed, reschedule with an interpreter or cultural liasion. 
3. Explain and confirm the referral or self-referral (Example- I see that we got a referral from Jane at Mounds View Schools.) 
4. Find out if there are any emergency, crisis or safety concerns that need to be addressed immediately. 
5. Give a brief overview- explain your role and what will happen during the intake.

EXAMPLE urgent safety concern (domestic violence; homeless and we don't have a safe place to sleep tonight)

EXAMPLE mental health crisis or emergency (recent suicidal ideation or plan)

If the caregiver answers YES or "I'm not sure"

Urgent concerns are TIME SENSITIVE, so you should focus on the urgent concerns and come back to the other questions later.

(EXAMPLE)  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.

Click here to close this form and open 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.

NOTE TO STAFF:

(EXAMPLE OVERVIEW) Most people call us their "collab family." 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.  

I'm a Family Support Specialist. RCCMHC has 16 staff and we all have different specialty backgrounds. We work as a team so you'll probably get to meet some of the others- but I'll be your main contact. 

Today, I'll be using something that we call our "sailboat form"- it's a Resource Navigation Tool that was originally created by our client families to guide our work. Our first intake meeting usually takes about an hour. You don't have to answer every question. If something is not important to you, we can skip it.

I'll start with some eligibility and consent questions. Then, I'll gather some basic information about your family. After we get that out of the way, we will spend the majority of our time talking about your child and family and what we can do to help.  The last thing I'll do is ask for your insurance information (if you have it) and I'll ask you to sign a release of information. 

NOTE TO STAFF Please use the EMAIL BUTTON in the referral tab of our Jotform table to re-send the Welcome Form.

If email is not available, copy and paste this link into Simple Texting and send it to the parent/caregiver. https://rccmhc.jotform.com/240965094486973

As the parent fills out the form, you can follow along with the questions below. 

What services are you interested in? 

• Resource navigation for basic needs or other family services
• Appointment setting and referrals for therapy or other therapeutic supports
• 3 Free Rapid Access sessions for therapeutic support (no diagnostic assessment needed)
• Care Team coordination (helping your family's providers to work together)
• Peer support and resilience coaching
• Virtual classes and programs for adults
• Virtual skills groups for kids/teens
• Family programs and Resource events

NOTE TO STAFF: don't spend a long time on this section. Just get a general idea of what the client would like. You (or the Peer Coach) will be able to discuss in detail at future check-in meetings. 

Eligibility- Do you have at least one child or teen who is struggling with emotions or behaviors?

• YES- I am the parent, foster parent or guardian of a child/teen who has a mental health diagnosis is struggling with emotions or behaviors that may put them at risk for a mental health diagnosis in the future
• NO
• Other

Eligibility- Do you meet Ramsey County criteria? (pick one.)

• My child that is struggling with emotions/behaviors currently lives in Ramsey County
• My child that is struggling with emotions/behaviors attends a school affiliated with Ramsey County
• We are homeless but still getting some services in Ramsey County
• Other

NOTE TO STAFF: If the parent/caregiver replies "NO" or "Other" to either of these questions and you have concerns about eligibility, explain that you will consult with your supervisor and we will follow up with the family within two business days. 

Cost: All RCCMHC services are free and voluntary. Referrals to external agencies may result in charges to your insurance/health care plan, co-pays or other fees. We will help you to find services you can afford. 

Programs and Supplies: New families are eligible to receive a CALM toolkit and Family Care Organizer. Throughout the year, we also give away gift cards and CALM Toolkit supplies with programs and classes. You must be present for the full program and you must place your order for supplies within 30 days. Gift cards are delivered through email or text message. Supplies are delivered to your home (for example; by Amazon.)

Information Sharing: Our staff are NOT county employees but we do work closely with the county, schools, hospitals, therapists, local healers and family service providers. RCCMHC will not share your information without your permission. If you need us to share information, you will sign a form called Authorization to Exchange and Disclose Information.

Mandated Reporting: 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, 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.

Calls and Texting: 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.

Custody: Parents/guardians who have permanently lost custody of their child are not eligible to get services through RCCMHC. Parent/guardians must let RCCMHC know if they lose permanent custody.

NAME: By entering your name here, you are stating that your eligibility information is true. You are also stating that you understand RCCMHC's terms and conditions and you consent to terms, conditions, and services as described.

Would you like to schedule an intake with RCCMHC:  Please instruct the parent/caregiver to select NO. This will skip them to the end of the form where they can select SUBMIT to save their responses. 

NOTE TO STAFF: If a family is NOT able to fill out the welcome form and submit it on their own, please collect their verbal consent below.

NOTE TO STAFF: After the welcome form is completed, select today's date below. Explain that the family will need to update their eligibility and contact info each year or earlier if their situation or contact info changes. 

NOTE TO STAFF: This is a good time to tell the parent/caregiver about our 1-800 Resource Line and help them to save the number in their cell phone contacts. (800-565-2575)

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."

OFFER 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.)"

MORE THAN ONE CHILD/TEEN: "If more than one child needs therapeutic supports, let's start with the child you are most concerned about."

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.

If it's easier, 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."

NOTE TO STAFF: If there have been frequent absences, complete the next 4 questions. If not, you can skip these. 

NOTE TO STAFF: You will update these charts each time you meet with the family.

NEW IN 2024-- checkboxes are for REQUESTED SERVICES and text boxes are for current services.

NOTE TO STAFF: If there are more children that need therapeutic support- be careful that you do not run out of time. Ask the parent/caregiver what they would like to do next. They may want to complete the intake by skipping to the Family Screening, Details and Next Steps sections. You can always add other children later. 

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."

OFFER 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."

NOTE TO STAFF: If there have been frequent absences, complete the next 4 questions. If not, you can skip these. 

NOTE TO STAFF: You will update these charts each time you meet with the family.

NEW IN 2024-- checkboxes are for REQUESTED SERVICES and text boxes are for current services.

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."

OFFER 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.

If it's easier, 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."

NOTE TO STAFF: You will update these charts each time you meet with the family.

NEW IN 2024-- checkboxes are for REQUESTED SERVICES and text boxes are for current services.

NOTE TO STAFF: These questions 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. 

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 

Explain: "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 for fun? What would be considered a 'good day' for your family?

Is there anything else you'd like to share about your family?

• 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

This might be a good time to ask if the parent/caregiver would like 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: You will update these charts each time you meet with the family.

NEW IN 2024-- checkboxes are for REQUESTED SERVICES and text boxes are for current services.

NOTE TO STAFF: Whenever possible, please upload a photo of the front and back of the insurance card to the Jotform Table. 

(see example below.)

NOTE TO STAFF: Ask the next question IF the family indicates they are on Blue Cross Blue Shield, Health Partners, Medica, UCare or United Healthcare.

NOTE TO STAFF: Ask the next question if the family answers 'NO' or "I'm not sure" to the previous question.

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. 

What is a 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. 

Authorization to Exchange and Disclose Information

The parent/guardian to adds their Care Team members to the Authorization to Exchange and Disclose Information form. This gives us permission to talk to and coordinate with them. The parentguardian can change the list of care Team members at any time. 

NOTE TO STAFF: each time you meet with a family, remember to check in about their priority needs and next steps. In order to keep track of referrals, you will need to update the list of requested services in sections Y1, Y2, Y3 and Family.  If a family needs many referrals or supports, you may need to schedule more frequent check-ins. 

•  For example, "Today, we talked about several resources that you need for your child/ for your family. Let's finish this meeting by choosing 3 priority needs. I'll work on setting up those referrals or supports for you and then we can meet again to check in and see what your next 3 priorities are."

A family might be working with other resource navigators, case managers or social workers. Double check with the family to make sure they still need the resources or supports that they identified at your last check-in. If many providers are involved, try calling a Care Team meeting so you can create a multi-system plan.

When a family needs less referrals, supports or check-ins... it may be time to "archive" the family to less intensive collab supports. 

Information below will appear in the auto-generated check-in email.

NOTE TO STAFF: If it seems like the family would benefit from Peer Coaching, you might invite the Peer Coach to the next check-in meeting. This can help with relationship building.

NOTE TO STAFF: If you add another staff member to the family's Care Team, consider inviting them to the next check-in meeting. If that's not possible, please call or text the family and let them know who the person is and why you want to add them temporarily to the Care Team BEFORe that staff person reaches out to the family. Reassure the family that you are still their primary contact.

NOTE TO STAFF: explain your follow up plan.

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 and a reminder about our next Check-In meeting. 

(INITIAL INTAKE-ONLY) In my email, I will include a link to your 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 Coach will reach out to you to help you place your order and tell you about a few more of our free services. I will include my email and phone extension and our 800# so you can call or text us anytime. I will also copy your referring provider if you gave us permission to do so.

________________________________

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 section of this form should be completed AFTER the intake.  

THIS SECTION IS FOR SUPERVISOR-ONLY:  when needed, MALEENIA will change the primary FSS staff who is working with a family...

• PAGE 1 change 1) the staff name and 2) the staff email. This will ensure that the new name and email appears on all referral forms etc. 
• Next, add the name(s) of any prior/past FSS staff below. 

1st Notice to REFERRING PROVIDER

After you have completed an intake, please click YES below to send an automatic email update to the referring provider. 

In the email, we provide the following information:

• The intake is complete.
• The name and email of the family support specialist.
• Our Authorization to Exchange and Disclose Information policy and process for sharing the Youth and Family Screening. 
• The password to access PDF protected documents if permisison is granted. 
• Our Resource Line number.