Progressive Steps Inc.
PRP Enrollment Form
For Office Use Only:
New
Re-auth
DATE OF REFERRAL:
*
-
Month
-
Day
Year
Date
CLIENT'S INFORMATION:
Client's Name:
*
DOB:
*
-
Month
-
Day
Year
Date
Age:
Address:
Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip
Home Phone:
-
Area Code
Phone Number
Social Security #:
Medical Assistance #:
*
Please indicate:
Sex:
*
Male
Female
Ethnicity:
Marital Status:
Single
Married
Divorced
Other
LEGAL CUSTODIAN:
(Not applicable if over the age of 18)
Are you the birth parent?:
Yes
No (If no please present one of the following documents)
Other
IMPORTANT: A LEGAL DOCUMENT MUST BE PRESENTED AT TIME OF INTAKE TO SHOW GUARDIANSHIP:
Court
DSS
Notarized letter stating your guardianship with at least one birth parent signature.
Name:
Relationship:
Home Phone:
-
Area Code
Phone Number
Work Phone:
-
Area Code
Phone Number
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERRAL SOURCE:
(If information is unknown, please insert "N/A" in the applicable box)
Agency:
Contact Person:
Therapist Name:
Email Address:
example@example.com
Phone:
-
Area Code
Phone Number
Ext:
Fax:
Address:
Address
Street Address Line 2
City
State
Zip
PRIMARY CARE PROVIDER:
(If information is unknown, please insert "N/A" in the applicable box)
Facility's Name:
Doctor's Name:
Phone:
-
Area Code
Phone Number
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client:
DOB:
/
Month
/
Day
Year
Date
Date:
/
Month
/
Day
Year
Date
DSM-V BEHAVIORAL DIAGNOSIS:
Diagnostic Category
Diagnosis Code
Description
1
2
3
Primary Medical diagnoses.(Primary medical diagnosis is required. Complete primary medical diagnostic category, medical diagnosis code and description.):
Diagnostic Category
Diagnosis Code
Description
1
2
3
SOCIAL ELEMENTS IMPACTING DIAGNOSIS (Check all that apply):
None
Problems with access to Healthcare services
Housing problems (not Homelessness)
Problems related to the social environment
Educational problems
Problems related to interaction with legal System/crime
Occupational problems
Homelessness
Financial problems
Problems with primary Support group
Other psychological and Environmental problems
Unknown
FUNCTIONAL ASSESSMENT:
(If information is unknown, please insert "N/A" in the applicable box)
Date of Diagnosis:
/
Month
/
Day
Year
Date
Assessment Measure/Score:
Measure:
Name & Title:
Presenting Complaint:
History of Presenting Problems:
By signing below, I acknowledging that all information provided is true and accurate to the best of your ability. This submission does serve as formal approval and submission of this form:
*
First Name
Last Name
Suffix
Signature/Title:
Date:
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: