• External Referral Form to LFS

    For any questions, please reach out to our referral team at Referrals@onelfs.org

  • Referring Provider Information:

  • Format: (000) 000-0000.
  • Is the client aware of this referral?*

  • Client Information:

  • Client's Date of Birth:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Client's Preferred Method of Contact:*
  • Format: (000) 000-0000.
  • Does the client have a legal guardian?*
  • Format: (000) 000-0000.
  • Primary Insurance:*
  • Secondary Insurance:*

  • Referral Information:

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  • LFS Program Categories (select each program to review available services; please select all programs and services that apply):*
    • Adult Behavioral Health Services (select all that apply) 

    • Mental Health

    • Substance Use

    • Medication Management

    • Peer Support: Mental Health / Substance Use

    • Is the client being referred involved in one of the following Treatment Courts: Drug Court, Mental Health Court, Veteran's Court, or DUI Court?*

    • Peer Support: Medication Assisted Treatment

    • Community Support

    • **Additional information is required when referring clients to Community Support. Please review/complete the additional questions below.**

      COMMUNITY SUPPORT REFFERAL INFORMATION

      For a referral to be considered complete and a Community Support Specialist assigned, all of the following documents are required:

      • Current (within the last year) Psychiatric Evaluation (PDE) or Initial Diagnositc Interview (IDI) that verifies SPMI diagnosis and 2 to 3 functional impairments. NOS/unspecified diagnoses do not qualify.
      • Biopsychosocial (BPA), strengths-based assessment completed or updated within 30 days of admission to Community Support Program.
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    • Assertive Community Treatment (ACT)

    • **Additional information is required when referring clients to ACT. Please complete the additional questions on the next page.**

    • First Episode Psychosis

    • Mobile Crisis Response

    • Children's Behavioral Health Services (select all that apply) 

    • Mental Health

    • Substance Use Disorder Treatement

    • Medication Management

    • RSafe

    • ABC Class

    • First Episode Psychosis

    • Community Treatment Aid

    • Mobile Crisis Response

    • Children & Family Services (select all that apply) 

    • Adoption

    • Family Centered Treatment

    • The Fatherhood Initiative

    • Foster Care

    • Kinship

    • Parent Education

    • Smart Gen Society

    • Refugee & Immigrant Services 

    • Refugee & Immigrant Services

    •  
    • At LFS, our Community Outreach and Intake Specialists are dedicated to supporting individuals who may face challenges or barriers to accessing care. They work closely with clients who need additional assistance navigating the registration and intake process, helping ensure that support remains accessible to those who need it most. Are there any barriers-such as transportation, technology, language, housing, or other challenges-that may make it difficult for this client to complete the registration/intake process independently?*

  • ACT Referral Form

  • Referral Source:

  • Client's Demographic Information:

  • Date of Birth (must be 18 years or older):*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Insurance Information:

  • Nebraska Medicaid Plan:*

  • Eligibility Criteria:

  • 1. Primary Mental Health Diagnosis (please check all that apply)*
  • 2. Presence of functional deficits in two of the three following functional areas: Vocational/Education, Social Skills, Activities of Daily Living (please check all that apply)*
  • 3. Does the individual show at least one of the following signs of ongoing high service needs? (please check all that apply)

  • Reason For Referral:

  • Chronological History of Behavioral Health Services Used in the Past 2 Years:

  • Service Providers & Supports:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is there an emergency contact for the individual?*
  • Format: (000) 000-0000.
  • Legal status (please check all that apply):*

  • Supporting Documentation

  • If available, please mark all that apply and upload documents below.
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  • Referrer Attestation:

  • I attest that, based on the information available, the individual appears to meet the medical necessity criteria for ACT or warrants evaluation for ACT under Nebraska service definitions.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Upon receipt, our team will review the referral form and supporting documentation for program enrollment and eligibility. Final eligibility will be determined in accordance with the Nebraska Department of Health and Human Services Division of Behavioral Health and Medicaid service definitions.

    For questions, please contact the ACT program at 402-909-9013. Thank you for your referral.

  • If you have any additional questions or want to learn more about our services, please call our office at 402-441-7940 or email us at referrals@onelfs.org

     

    PLEASE CLICK "SUBMIT" BELOW TO FINISH THIS REFERRAL

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