True Heart PRP REFERRAL FORM
INTRODUCTION TO PRP REFERRAL FORM
Thank you for your interest in partnering with True Heart to serve minors and adults working towards achieving their individual rehabilitation goals. Once you complete this referral form, here's what you can expect: 1. We will review the completed referral to ensure all required information is provided, 2. We will submit this referral to Optum (Administrative Service Organization) to request approval/authorization to serve this individual, 3. Once approval/authorization is received, we will contact the participant to schedule an orientation so they are aware of how PRP services will be provided, and their rights and responsibilities. Lastly, a member of our PRP team will contact the licensed mental health professional serving the participant to begin working in collaboration to assist them in achieving their goals.
Date of Referral
Date Intake Form completed
ELIGIBILITY FOR PSYCHIATRIC REHABILITATION SERVICES (PRP)
To be eligible for PRP services, the answer to the following questions must be YES.
Is the person making this referral a licensed mental health professional? Or, is the person making this referral a stakeholder working on behalf of participant and collaborating with the licensed mental health professional?
Is the participant currently engaged in active outpatient therapy with a licensed mental health professional?
Does the participant have Medicaid Insurance?
Have less intensive services been tried before making this referral for PRP services?
Can the participants mental status or developmental level be reasonably accommodated via PRP services?
Primary etiology or dysfunction is not related to organic syndrome, intellectual disability, neurodevelopmental disability or neurocognitive disorder.
Yes (none of the listed dysfunctions apply)
No (at least one of the listed dysfunctions apply)
If you answered NO to any of the above questions, please stop and contact True Heart at 410.596.4428 to discuss participant's eligibility!
Is the person making this referral currently serving as the participants therapist?
Referral Contact - Name & Credentials
Licensed Mental Health Professional
Name of agency or practice
Referral Contact - Phone #
Referral Contact - Email Address
New Referral or Re-Admittance?
Mental Health Diagnosis - Primary (DSM-5)?
Mental Health Diagnosis - List any additional diagnosis here
Is participant? (these services may exclude participant from receiving PRP services)
Eligible for full funding for Developmental Disabilities Administration (DDA) services
Actively receiving autism waiver funded services
Active in Applied Behavioral Analysis Treatment
Reason for Referral?
Functional Impairment: YOUTH only! Youth must have exhibited at least 1 functional impairment. Please list and objectively describe examples of impairment caused by the symptoms of the participants diagnosis.
Functional Impairment: ADULT only! Adult must have exhibited at least 3 functional impairments. Please list and objectively describe examples of impairments caused by the symptoms of the participants diagnosis.
Has pharmacotherapy been tried or considered? If yes, please describe treatment and outcome. If no, please describe why pharmacotherapy was not tried or considered.
Does consumer have any of the following available at time of referral?
Individualized Rehabilitation Plan
Individualized Education Plan
Person Centered Plan
Individualized Plan for Employment
If participant has an Individualized Rehabilitation Plan (IRP), please check all that apply:
IRP goals are active and will still be valid at the start date of requested PRP services?
IRP includes signature of person who created the plan?
IRP signed by the participant or participants guardian
Please attach any relevant files (assessment, IRP, IPE, IEP, authorizations, etc.)
Drag and drop files here
Choose a file
Only complete this section for referrals of youth (under the age of 18)
Does the youth's mental health diagnosis/impairment result in any of the following?
Current threat to the youth's ability to stay in customary settings, or
Emerging/impending risk to the safety of the youth and others, or
Other evidence of significant or social impairment (for example, social behaviors causing serious problems with peer relationships and/or family)
Due to dysfunction, youth is at risk for requiring a higher level of care or returning to higher level of care.
Has less intensive services been tried before seeking PRP services? If yes, please describe the less intensive services tried (group therapy, supported employment, target case management, peer natural supports, etc.)
Therapy and/or Medication Management treatment is (check all or any of the following that apply}:
Not preventing clinical deterioration
Not averting need for a more intensive level of care
Youth is (check all or any of the following that apply)
Transitioning from IP, day hospital or RTC
In need of PRP services to prevent clinical deterioration
Being referred to avert need for more intensive level of care
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Participant's Phone # - Primary
Please enter a valid phone number.
Participant's Marital Status
Single - not married
N/A - Child/Youth
Participant's current or highest level of education?
Participant's employment status
If not applicable - N/A
Does participant have a criminal background?
Is participant a veteran?
Does Parent(s) have legal custody of the minor?
If consumer is an adult (age 18 or over), do they have a legal guardian?
If parent does not have legal custody, please provide custodial information
Name & Phone Number
State / Province
Postal / Zip Code
Should be Empty: