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:
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.Format: (000) 000-0000.
Date of birth:

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

First NameLast Name
Does contact person have legal custody?
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.Format: (000) 000-0000.
Relationship:
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):
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):
Semi-independent living skills (check all that apply):
Interactive skills with others (check all that apply):
Leisure social skills:
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:
NPI Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Mental health treatment currently being provided:
Signature & Date
Supervisors name & credentials (LGPC/LMSW)

First NameLast Name
NPI number

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
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: