ECM Pre-Qualification Applications Options

This application can be filled in online using the form below or you may download a PDF form that you can fill out and email to us.

Download PDF Form

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Email form here when completed:
ecmteam@linkslo.org

ECM Pre-Qualification Application

Important Note - For required fields use NA or Not Applicable or Unknown, Please fill this form to the best of your abilities this will help us to process it with the best poseable outcome in the shortest time.

Section 1 Member Information

Note Expedited applications will be handled first please insure the form is as accurate and complete as possible.

Referral Date

Referral TypeReferral TypeRoutineExpedited

Member Last Name

Member First Name

Date of Birth

Age

Preferred Language

Medi-Cal CIN

CenCal Member ID

Primary Phone

Member Email

Residential address

No fixed current address

Frequently visited location

City

State

ZIP

Section 2 Member Care Provider

Note Expedited applications will be handled first please insure the form is as accurate and complete as possible.

Primary Care Provider / Clinic

Best Contact MethodBest Contact Method PhoneEmailText

Best Time to CallIf not applicable indicate with NA

Section 3 Parent / Gardian

Note Expedited applications will be handled first please insure the form is as accurate and complete as possible.

Parent / Guardian name

Parent / Guardian Relationship

Parent / Guardian phone

Parent / Guardian email

Section 4 Member Involvement / Consent

Note

Is the Member Aware of Referral?Is the Member Aware of Referral?YesNoUnknown

Member Has Agreeded to Contact?Member Has Agreeded to Contact?YesNoUnknown

Section 5 POV Area

Note

Adults experiencing homelessnessAdults experiencing homelessnessYes

Adults at risk for avoidable hospital or emergency department utilizationAdults at risk for avoidable hospital or emergency department utilizationYes

Adults with serious mental health and/or substance use disorder (SUD) needsAdults with serious mental health and/or substance use disorder (SUD) needsYes

Adults transitioning from incarceration / correctional facility within the past 12 monthsAdults transitioning from incarceration / correctional facility within the past 12 monthsYes

Adults living in the community who are at risk for long-term care (LTC) institutionalizationAdults living in the community who are at risk for long-term care (LTC) institutionalizationYes

Adult nursing facility residents transitioning to the communityAdult nursing facility residents transitioning to the communityYes

Birth Equity - pregnant or postpartum individuals at risk for adverse perinatal outcomesBirth Equity - pregnant or postpartum individuals at risk for adverse perinatal outcomesYes

Enter the criteria or supporting information that applies.

Section 6 Children POV Area

Note Select all that apply

Children/youth experiencing homelessness, including families with children/youthChildren/youth experiencing homelessness, including families with children/youthYes

Children/youth at risk for avoidable hospital or emergency department utilizationChildren/youth at risk for avoidable hospital or emergency department utilizationYes

Children/youth with serious mental health and/or substance use disorder (SUD) needsChildren/youth with serious mental health and/or substance use disorder (SUD) needsYes

Children/youth enrolled in CCS or CCS Whole Child Model with additional needs beyond the CCS conditionChildren/youth enrolled in CCS or CCS Whole Child Model with additional needs beyond the CCS conditionYes

Children/youth transitioning from a youth correctional facility, or transitioned within the past 12 monthsChildren/youth transitioning from a youth correctional facility, or transitioned within the past 12 monthsYes

Children/youth involved in Child Welfare / foster care / qualifying adoption or family maintenance servicesChildren/youth involved in Child Welfare / foster care / qualifying adoption or family maintenance servicesYes

Children/youth with an intellectual or developmental disability (I/DD) and qualifying additional ECM needsChildren/youth with an intellectual or developmental disability (I/DD) and qualifying additional ECM needsYes

Birth Equity - pregnant or postpartum youth at risk for adverse perinatal outcomesBirth Equity - pregnant or postpartum youth at risk for adverse perinatal outcomesYes

Member Child POF DetailsMember Child POF Details

Member Last NameKnown medical diagnoses / significant health conditions

Enter known behavioral health, mental health, or substance use needs.

Enter recent ED visits, hospitalizations, skilled nursing stays, or crisis services.

Housing / safety / food / transportation / caregiver / other social needs

Reason for ECM referral / what support is being requestedA full explanation is required Do Not indicate Not Applicable

Organization / agency

Organization NPI (if applicable)

Person Referring

Title / Role

Phone

Email ( (Note: Confirmation email will be sent here)

Relationship to Member

Provider organization and/or care manager

List other programs or services currently involved.

Additional comments / information needed to complete the official CenCal ECM referralAdditional comments / information needed to complete the official CenCal ECM referral

Information is accurate to the best of my knowledge and may be used to determine ECM eligibility.Information is accurate to the best of my knowledge and may be used to determine ECM eligibility.I attest to the statement above.

Type ypour full name here as your signature

Signature Date

You do not have to manage everything on your own.

Enhanced Care Management (ECM) provides consistent. coordinated, and long-term support to help individuals and families move toward greater stability, health. and overall well-being. Through personalized Care coordination, community connections, and ongoing follow-up. ECM helps remove barriers that can make daily life overwhelming,

At The Link Family Resource Center. we walk alongside you every step of the way. Whether you need help navigating healthcare systems. finding housing resources. accessing food support. coordinating behavioral health services. supporting your children in school or connecting to community programs our team is here Whelp you feel supported - not forgotten.

Get Connected

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Lead Care Manager:
Carmen Del Real

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Phone:
805-503-9638

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Email:
cdelreal@linkslo.org