Jail MAT Program Referral Form | Ingham County, MI
The Ingham County Correctional Facility uses this one-page form to refer people in custody to its medication-assisted treatment (MAT) program. The form records booking and release information, opioid use history, overdose history, current or past MAT medications and providers, housing plans after release, and case worker assignments. It closes with a consent statement that staff read aloud, which asks the person to agree to share protected health information among mental health, medical, health department, and custody staff.
How to use it
Use the form as a starting point for a referral process that all partners share. A single document records who made the referral, who received it, and the assigned case worker at each partner agency, and it asks about the estimated release date and housing plans at the point of referral. To adapt it, replace the partner agencies, medication list, and email routing with your own, and decide which fields your team requires to make a clinical decision. Have legal counsel review the consent statement before using it, because it was written to Michigan and federal health privacy law.
Who might use it
Jail medical staff, jail administrators, and MAT program coordinators who are starting or formalizing a referral process inside a correctional facility are the main audience. Community mental health agencies, reentry case managers, and peer recovery programs that receive referrals from a jail may also find it useful, as may COSSUP grantees that are connecting jail-based treatment to care after release.