Pair Team - ECM Referrals Form

Pair Team - ECM Screening Form
Thank you for taking the time to screen yourself or someone else to the Enhanced Care Management program! Please confirm that the person being screened falls into one of the following categories:
1. Experiencing homelessness, at risk of homelessness, or fleeing domestic violence
2. High emergency department use
3. Severe mental illness
4. Substance abuse disorder
5. Adults Living in the Community and at Risk for LTC Institutionalization
6. Adults Nursing Facility Residents Transitioning to the Community
7. Intellectual or developmental disabilities (I/DD)
8. Transitioning from incarceration
9. Prenatal or postpartum
10. Children enrolled in CCS or Child Welfare
Once this screening form is submitted, we will reach out to the phone number provided below within 1 business day to enroll the screened person into the Enhanced Care Management program. For any additional questions about us, please contact ECM@pairteam.com. The privacy policy and terms of use of the Pair Team website applies to this form. If you want more information please see here.

If you need help filling out the form or want to learn more about ECM, reach out to 909-743-5915!
PLEASE NOTE: ECM enrollments for LA Care health plan are currently paused, and will continue to be paused for at least 60 days

If you or your client are members of LA Care health plan, please seek alternative services until ECM enrollments are unpaused.
Full name of client*

First NameMiddle NameLast Name
Does the client have Medi-Cal coverage?*

YesNo
Organization you are submitting from*
if this section was automatically pre-filled, please do not edit the name of the organization. It is important that your organization consistently submits each screening under the EXACT same name.

Client birth date*

MonthDayYear
Date
Client's Contact Number (we will text and call)*
Please enter a valid phone number.
Who are you screening?*

MyselfSomeone else

(Optional) Client's Current Clinic
Client's Current Clinic
Name of person submitting screening (your name)

First NameLast Name
Is the Client a regular client of your organization? Answer yes if the screened person is involved in a regular program at the organization, such as a resident of a housing facility or a client in a case management program.

YesNo
Can we follow up with you regarding this screening?

YesNo
If yes, what is your best contact number / email?
If yes, what is your best contact number / email?

Would you like to share any additional notes?
By checking this box, you agree the individual being submitted has consented to sharing their information for engagement and treatment purposes.*

Agree

Thank you for filling out the form. Unfortunately, your answers have indicated the person being screened is not eligible for Pair Team's Enhanced Care Management program because they do not fit into one of the required populations to qualify for the program.

PLEASE NOTE: ECM enrollments for LA Care and Molina health plans are currently paused, and will continue to be paused for at least 60 days

If you or your client are members of LA Care and Molina health plans, please seek alternative services until ECM enrollments are unpaused.
Should be Empty:

Pair Team - ECM Screening Form

(Optional) Client's Current Clinic