CORE Referral Form Page MHA Rochester CORE Referral Form Please complete the form below. If you have any questions, please contact Ron Ehle, Director of Community Based Peer Support for Adults at (585) 325-3145, x650. CompanyThis field is for validation purposes and should be left unchanged.Date(Required) MM slash DD slash YYYY Name(Required) First Last Phone #(Required)Date of birth(Required) MM slash DD slash YYYY Gender(Required)Race/Ethnicity(Required)Primary Language Spoken(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant Health Care InformationManaged Care Organization(Required) Excellus Fidelis Molina MVP United Select One(Required) Tier 1 Tier 2 Policy # or Plan ID(Required)BH Primary Diagnosis (ICD-10 F Code)(Required)MCO Contact Name (First, Last)(Required)MCO Contact Phone #(Required)MCO Contact Email(Required) Medicaid CIN(Required)Referral SourceName (First, Last)(Required)Agency Name(Required)Agency Phone #(Required)Email(Required) Agency Fax #(Required)Any Known Safety Concerns? If none, list "N/A"(Required)Examples: History of violence, weapons in the home, dogs, sex offender, general concerns, etc. If none, list "N/A"Any Identified Service Restrictions Surrounding Participant Availability? If none, list "N/A"(Required)Download a blank PSYCKES Consent Form: Click here to download PSYCKES Consent(Required)Upload a signed PSYCKES consent form to help us better coordinate care and connect the individual with appropriate CORE services.Max. file size: 300 MB. MHA Rochester Services(Required)Please select the service(s) you are interested in. CORE Psychosocial Rehabilitation PSR - Employment PSR - Education Empowerment Services (Peer Supports) Family Support & Training CAPTCHA