Fresno County Assisted Outpatient Treatment (AOT) Referral Form Please complete and email the form to DBHAOT@fresnocountyca.gov Referrals are for adults only. The AOT Program does not have the authority to mandate medication or involuntary long-term hospitalization/conservatorship. If you have any questions, please email DBHAOT@fresnocountyca.gov
Date:	Referring Party Name/Agency:
Referring Party Contact Phone Number(s):
Referring Party Email Address:
If Applicable, name of interpreter and language spoken by referring party:
Criteria 1: The referring party is 18 years or older and (must choose 1) (CA WIC § 5346):
Cohabitating with Person Parent Spouse Sibling Child of the Person Director of a Public or Private Agency Treatment Facility Charitable Organization	Licensed Residential Facility Director of a Hospital (where Person is currently hospitalized) Licensed Mental Health Treatment provider (supervising treatment of or providing treatment for Person) Peace/Probation/Parole Officer (assigned to Person) Superior Court Judge
Person’s Name:	Gender:	M F Other:
Person’s Phone Number(s):	Birthdate:	Click or tap to enter a date.
Criteria 2: Is Person Served present or reasonably believed to be present within Fresno County (CA WIC § 5346)? YES NO
Person’s Address/Location:
Criteria 3: Psychiatric Diagnoses (DSM 5): Check all that apply (CA WIC § 5346 & § 5600.3):
PTSD Schizophrenia Bipolar Disorder Substance Use Disorder(s):	Other severely disabling mental disorders (e.g., major affective disorders, disorders with symptoms of psychosis and/or that cause substantial functional impairments or symptoms, etc.):
Criteria 4: Clinical determination (per treatment history and current behavior): Must choose at least 1 (CA WIC § 5346):
Person unlikely to survive safely in the community without supervision and their condition is substantially deteriorating. If checked, please explain:
Person needs AOT in order to prevent relapse or deterioration that may result in grave disability or serious harm to the Person or others (CA WIC § 5150). If checked, please explain:
Criteria 5: There is history of lack of adherence with Mental Health (MH) treatment at which: Must choose at least 1 (CA WIC § 5346): *Do not include any period during which person was hospitalized or incarcerated right before the filing of this form*
Mental illness has resulted in Person needing hospitalization or services in a forensic or other MH unit of a state or local correctional facility at least 2x in the past 36 months (3 years.). If checked, please explain:
Mental illness has resulted in 1 or more serious and violent behavior towards themselves or others or threats or attempts to cause serious physical harm to themselves or others in the past 48 months (4 years). If checked, please explain:

To be Completed by DBH Staff	Date Received:
Date Reviewed and Reviewed By:
Would participation in AOT be the least restrictive placement to ensure recovery and stability?
Date of Referral Approval or Denial*:
*If Referral is DENIED, explain why: