Child & Adolescent PRP initial referral form-Catonsville Staff

Child & Adolescent Psychiatric Rehabilitation Program (PRP)

Referral Form
Date referral should be added:

MonthDayYear
Date
Identifying Information
Child's Name:*

First NameLast Name
Child's sex:*

MaleFemale
Child's Pronouns*
Child's Gender Identity*
Child's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact number:*
Please enter a valid phone number.
Date of birth:*

MonthDayYear
Date
Child's age:*
Social security #:
no characters/numbers only
Medical assistance #:*
Access to transportation for on-site activities:

YesNo
Adult's contact name:*

First NameLast Name
Does contact person have legal custody?*

YesNo
Contact person's address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact person's phone:
Please enter a valid phone number.
Relationship:*

ParentLegal GuardianFoster Care Provider
DSM V diagnoses:

A minor must have a behavioral diagnosis and be referred by a Licensed MH Professional to be eligible for PRP
Behavioral diagnosis(es) (ICD-10 diagnosis(es) code required):*
diagnosis code & description
Primary Medical Diagnosis(es) (required if applicable):
description
Social elements impacting diagnosis (required):*

NoneEducationalFinancialAccess to health careLegal system/crimePrimary supportHousingOccupationalSocial environmentHomelessness*Other psychosocial & environmentalUnknown
If other psychosocial & environmental elements, please explain below:*
Source of diagnosis:*
Functional assessment (if applicable):
Measure used:
Score:
Reason for referral (Indicate the areas you want the PRP to address)
Self care skills (check all that apply):

personal hygiene/groomingnutrition/dietary planningdressing selffollowing routines (bed, school)toiletingself administration of meds
Semi-independent living skills (check all that apply):

taking care of belongingsmoney managementmaintain living areamobility skillssafety skillsaccessing entitlements
Interactive skills with others (check all that apply):

interactive skills with peersinteractive skills with familyinteractive skills with adults
Leisure social skills:

community integrationparticipation in activitiesdeveloping natural supports
Anger management skills:
additional info (if needed)
Education:
additional info (if needed)
Symptom management:
additional info (if needed)
Community/Family Resources:
additional info (if needed)
Other reasons:
additional info (if needed)
Licensed Mental Health Professional Providing Referral:
Name & credentials*
Agency/Organization:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mental health treatment currently being provided:*

Outpatient Mental Health ServicesInpatient Mental Health ServicesResidential Treatment Center
Signature & Date*

Clear
Supervisors name & credentials (LGPC/LMSW)

First NameLast Name

Professional Assertion of Need for PRP Services
Child's Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
In order for a child to receive PRP services, he/she must meet certain medical eligibility criteria. The referring Mental Health Professional must provide assertion that the minor meets all of the clinical criteria outlined below:
Signature, Date and credentials*

Clear
Printed name and credentials of MH professional providing assertion:*

First NameLast Name
Key Point Health Services, Inc.

Child & Adolescent Psychiatric Rehabilitation Program (PRP)
Should be Empty: