Behavioral Health Links (90-day Pre-Release Medi-Cal services)

Use this form to refer Justice-Involved (JI) individuals who meet eligibility criteria for linkage to Marin County Behavioral Health and Recovery Services (BHRS) under the Justice-Involved (JI) CalAIM initiative.

Please attest to the following prior to submitting this form:*

To the best of my knowledge, the Justice-Involved Individual being referred is eligible for a BHLink and has expressed their willingness to engage in voluntary Behavioral and/or Substance Use services in Marin County upon release.The Justice-Involved Individual being referred consents to their medical records being shared for care coordination and treatment purposes with Marin County BHRS.

Upload a signed ROI *

Referring Party

Name*

First NameLast Name

Title/Position*

Agency/Correctional Facility*

Email address*

example@example.com

Phone Number*

Please enter a valid phone number.

Alternative contact if different than the person submitting this referral

Justice-Involved Individual

Full Name*

First NameLast Name

Any known aliases

Date of Birth*

MonthDayYear

Medi-Cal ID number*

Client Identification Number/Social Security Number

Known or estimated release date*

MonthDayYear

Eligibility Criteria

The referred individual is 18 years old or older, or will be at the time of release.

YesNo

They intend to reside in Marin County upon release (Please ensure appropriate transportation is secured from the correctional facility if applicable.)

YesNo

This form is for adult care only. If you need to refer a justice-involved minor and don't know where to send the Link, please email Matt Carter

This form is for Marin County residents only. Please direct this link to the County the referred individual intends to live in upon release.

What will their address be? (If unsheltered, likely future known locations)

Do they anticipate being reachable by phone within a day or two following their release, either directly or via a community member?

YesNo

List phone numbers and/or all community contacts able to assist in communicating with the referred individual after their release.

The referred individual’s JI code has been activated and they have active Marin County Medi-Cal or “conditional eligibility” under the Medi-Cal’s Accelerated Enrollment (AE) program.*

Yes, JI code has been activated

They carry at least one of the following:*

Confirmed or suspected mental health disorder diagnosisConfirmed or suspected substance use disorder diagnosis

This form is for adult behavioral and substance use care only. Please contact the referred individual's Managed Care Plan for all other needs

List mental health diagnoses*

List substance related diagnoses*

Services requested*

Specialty Mental Health Services (SMHS)Drug Medi-Cal Organized Delivery System (DMC/DMC-ODS)Other, please explain

Managed Care Plan

Please confirm you have notified their Managed Care Plan that care coordination is occurring with Marin County BHRS (If you have not, please cc HHSBHLinks@marincounty.gov when emailing them to facilitate coordination.)

Please provide their Enhanced Care Manager’s name and contact information (if applicable)

Confirm you have or will within 2 business days of this referral provide Marin County BHRS with all relevant medical records.*

I confirm

Please upload the incarcerated person’s relevant medical records here. (If uploading is not possible, you can either email the records to HHSBHLinks@marincounty.gov or fax them to 415.634.1947.)