Child & Adolescent PRP initial referral form-Catonsville Staff

Child & Adolescent Psychiatric Rehabilitation Program (PRP)

Referral Form
Date referral should be added:

Month Day Year
Date
Identifying Information
Child's Name: *

First Name Last Name
Child's sex: *

Male Female
Child's Pronouns *
Child's Gender Identity *
Child's address *

Street Address

Street Address Line 2

City State / Province

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

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

Yes No
Adult's contact name: *

First Name Last Name
Does contact person have legal custody? *

Yes No
Contact person's address (if different):

Street Address

Street Address Line 2

City State / Province

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

Parent Legal Guardian Foster 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): *

None Educational Financial Access to health care Legal system/crime Primary support Housing Occupational Social environment Homelessness *Other psychosocial & environmental Unknown
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/grooming nutrition/dietary planning dressing self following routines (bed, school) toileting self administration of meds
Semi-independent living skills (check all that apply):

taking care of belongings money management maintain living area mobility skills safety skills accessing entitlements
Interactive skills with others (check all that apply):

interactive skills with peers interactive skills with family interactive skills with adults
Leisure social skills:

community integration participation in activities developing 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

City State / 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 Services Inpatient Mental Health Services Residential Treatment Center
Signature *

Clear
Supervisors name & credentials (LGPC/LMSW)

First Name Last Name

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

First Name Last Name
Date of birth: *

Month Day Year
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 and credentials *

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

First Name Last Name
Key Point Health Services, Inc.

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

Child & Adolescent Psychiatric Rehabilitation Program (PRP)

Identifying Information

DSM V diagnoses:

Reason for referral (Indicate the areas you want the PRP to address)

Licensed Mental Health Professional Providing Referral:

Professional Assertion of Need for PRP Services

Key Point Health Services, Inc.