Diagnostic Script for Adult Certified Peer Support Services

Patient Name*

First NameLast Name

Date of Birth*

Date

Patient Age*

I am recommending certified peer support services for the above patient for the following reasons:

Complete ALL 2 Sections

1. Have a presence or history of a serious mental illness:

At any time during the past year, had a diagnosable mental, behavioral, or emotional disorder that met the diagnostic criteria within the current DSM. (*Substance abuse disorders, developmental disorders, autism, or
Dementia/Alzheimer’s alone are excluded*) An individual may have one of these aforementioned diagnosis(es) but must have a mental health diagnosis as the primary area of focus and/or concern.

List Mental Health diagnosis(es) (Put N/A if not applicable):*

List Intellectual Disability, Developmental Disorder, Autism, Substance Disorder diagnosis(es) (Put N/A if not applicable):*

2. Functional Impairment

Diagnosis(es) has/have resulted in functional impairment and which substantially interferes with or limits one
or more major life activities. Adults who would have met functional impairment criteria during the referenced
year without the benefit of treatment or other support services are considered to have serious mental illness.

Difficulties that substantially interfere with or limit: (TO BE ELIGIBLE, individual must meet ONE of the
following. Please check off as appropriate)

Please check off as appropriate:*

A person from achieving or maintain one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills;Role functioning in one or more major life activities including basic daily living skills (e.g., eating, bathing, dressing);Instrumental living skills (e.g. maintaining a household, managing money, getting around the community, taking prescribed medication); andFunctioning in social, family, and vocational/educational contexts.N/A

Licensed Practitioner's Name*

First NameLast Name

Licensed Practitioner's Credientials*

Telephone*

Please enter a valid phone number.

NPI #*

Signature*

(Indicate Credentials: Licensed practitioner of the healing arts—LPHA: (i) A person licensed by the Commonwealth to practice
the healing arts. (ii) The term is limited to a physician, physician’s assistant, certified registered nurse practitioner,
psychologist, licensed clinical social worker, licensed professional counselor, and licensed marriage and family therapist.)
**Provider must be enrolled in Promise.