Referral Form

Initial Concurrent PRP

Consumer Name *

Date of Birth *

MA Number

Parent/Legal Guardian Name

Phone Number *

Date

Address

Race/Ethnicity

Social Security Number

Gender

Marital Status

Highest Level of Education

Employment Status

Living Situation

Transition Age Youth

Yes No

Number of Arrest in past 30 Days

Veteran

Yes No

Is individual in active mental health treatment?

Yes No

What is the duration of current episode of treatment provided to this Individual

Current Frequency of treatment of provided for this this Individual

Have you Ever Been in any PRP in the Past:

Yes No

Does consumer meet Maryland's Department of Health and Mental Hygiene's Priority Population criteria?

Yes No

Is the PPD diagnoses considered to be severe, chronic and is characterized by impaired role functioning?

Yes No

Social Elements Impacting Diagnosis

Reason for Referral/ Presenting Issues / Progress Made (Include symptoms, ER visits and other crisis interventions)

Medical Necessity

ADULT criteria for admission For PRP (PLEASE CHECK ALL THAT APPLY AND COMMENT WHERE CHECKED)

The consumer has a serious mental health disorder. A clear, current threat to the individual's ability to manage current living situation. An inability to be employed or attend school without support. There is clinical evidence that the current intensity of outpatient treatment will not be sufficient to reduce the client's symptoms and functional behavioral impairment resulting from mental illness and restore him/her to appropriate functional level. There is evidence that PRP services will be necessary to prevent clinical deterioration and support successful transition back to the community. The individual's condition requires an integrated program of rehabilitation services to develop and restore independent living skills to support the individual's. The individual disorder can be expected to improve through medical necessary rehabilitation or clinical evidence that this intensity of rehabilitation is needed to maintain the individual level of functioning and is judged to be in enough behavioral control to be safe in the rehabilitation program and benefit from rehabilitation provided.

Clinical Rationale For Diagnosis (Include Summary of last Visit e.g Presenting problem)

Provider/Referral Source Information

Referring Clinician Name & Credential

Agency name & Address

Date

Phone Number

Fax Number

Email Address *

Psychosocial Report included?

Yes No

Individualized Treatment Plan(ITP) included?

Yes No

Signature

Phone

Email

ADULT AND YOUTH PRP REFERRAL FORM

ADULT AND YOUTH PRP REFERRAL FORM

( Psychiatric Rehabilitation Program PRP )

Social Elements Impacting Diagnosis

Medical Necessity

Clinical Rationale For Diagnosis (Include Summary of last Visit e.g Presenting problem)

Provider/Referral Source Information

Quick Links

Services

Information

Phone

fax number

Email

Location