SMI Referral Form

How do I request an SMI evaluation?

After you submit this form, one of our coordinators will contact you to provide information and discuss the upcoming evaluation. The individual receiving the evaluation will need to provide verbal consent to continue with the scheduling process. Please be prepared to complete a 15-minute screening(if applicable)to help complete the evaluation process. Contact us at (480) 804-9542 if you need any assistance filling out the form or if you have any questions.

Who is eligible for an evaluation?

Adult individuals, 18 or older, are eligible for an evaluation. Individuals who are 17 years and six months old or are within 7-10 days of turning 18 years old are completed on a case-by-case basis. CPR will attempt to help transition from child to adult services. Any Maricopa County resident that has not had a determination of SMI eligibility within the previous six months is eligible to be evaluated. CPR can provide evaluations for clients in other counties on a case-by-case basis.

Private or public insurance is not needed to complete a SMI evaluation. There is no cost to the client or private insurance plans.

Important information about the evaluation and services

Most evaluations typically last between 1-2 hours. A relative or advocate may accompany you during the evaluation process at your request. You will be asked to sign a release of information in the event that you would like someone to accompany you during your evaluation.

The Department of Behavioral Health Services requires clients to prove their identity (ID) and lawful presence (LP) to be eligible for the SMI program. Please provide (or be able to provide) a state-issued ID, birth certificate, passport, etc. Clients currently enrolled in AHCCCS do not need to provide ID and LP. Clients who are on Medicare do not need to provide LP. Social security cards do not count as LP.

Telehealth evaluations

CPR offers the opportunity to complete SMI evaluations through video conferencing using secure software. The technology is safe and HIPAA compliant. Completing an evaluation in this manner, however, does require a certain level of technological understanding and planning on your part.

Telehealth evaluations

You will be notified of your SMI evaluation outcome via mail by Solari once a decision has been made. Please feel free to contact Solari regarding any questions regarding your evaluation at 1-855-832-2866.

Routine

Evaluations that are scheduled to be completed via telehealth or at one of our outpatient locations. Typically completed within 7 days or less from request. Individual consent and phone screening required prior to scheduling. Please see the telehealth guidelines below.

Urgent

Evaluations that are completed within 24 hours of the request while a client is in an in-patient setting. Typically a behavioral health professional requests the evaluation on behalf of the client. Evaluations are typically provided in person at the facility or via telehealth. Please submit client records with the referral. The packet needs to include the following: face sheet, MAR, H&P, Initial Psych Evaluations, labs, and the last three days of progress notes.

Jail

Evaluations that are completed for clients who are currently incarcerated within Maricopa County. Typically clients are seen via telehealth or in person. These evaluations can be requested by jail staff using this link or by the client directly via postcard addressed to: 1400 E Southern Ave, Suite 735, Tempe, AZ, 85282.

Prison

Evaluations that are completed for clients who are currently incarcerated within the state of Arizona. All prison evaluations are requested by prison staff as clients approach a release date. SMI services cannot be provided while in prison, even if clients are determined SMI.

Special Needs

CPR is able to accommodate most special needs and will be evaluated on a case-by-case basis.