PRP Referral Form (Minor)

PRP Referral Form (Minor)

4325 Forbes Blvd, STE E, Lanham, MD 20706 Email: info@youfirsthealthsystems.com Phone: 301-329-0177
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender
Client Address

Street Address

Street Address Line 2

CityState

Zip Code
Client E-mail
Client Phone Number:*
Client Social Security Number
enter your 9 digit SS#
Client Medicaid #
Parent/Guardian Contact:

First NameLast Name
Relationship
Parent/Guardian Contact Number
Parent/Guardian E-mail
example@example.com
ICD-10 Diagnosis
Client Medication(s)
CLINICAL INFORMATION:
Is youth currently in mental health outpatient or inpatient treatment?*

YesNo
The youth has been engaged in active, documented outpatient treatment for:

Less than one monthBetween one and three monthsSix months or more
Current frequency of treatment provided to this individual:

At least 1x/ weekAt least 1x/ 2 weekAt least 1x/ monthAt least 1x/ 3 monthsAt least 1x/ 6 months
In the past three months, how many ER visits has the youth had for psychiatric care?

No visits in the last three monthsOne visit in the last three monthsTwo or more visits in the last three months
Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting

YesNo
Does the youth have a Targeted Case Management referral or authorization?

YesNo
Has medication been considered for this youth?

Not ConsideredConsidered and Ruled OutInitiated and withdrawnOngoingOther
FUNCTIONAL IMPAIRMENT(S):

1. Describe the individual's emotional disturbance below:
a. A clear, current threat to the youth's ability to be maintained in their customary setting?

YesNo
Evidence of a clear, current threat to the youth's ability to be maintained in their customary setting:
b. An emerging risk to the safety of the youth or others?

YesNo
Evidence of an emerging risk to the safety of the youth or others:*
c. Significant psychological or social impairments causing serious problems with peer relationships and/or family members?

YesNo
Significant psychological or social impairments causing serious problems with peer relationships and/or family members?
2. What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth's symptoms and functional behavioral impairments resulting from mental illness?
3. How will PRP serve to help this youth get to age appropriate development, more independent functioning and independent living skills?
4. Has a crisis plan been completed with family and/or guardian?

YesNo
5. Has an individual treatment plan/Individual rehabilitation plan been completed?

YesNo
LICENSCED MENTAL HEALTH PROFESSIONAL PROVDING REFERAL:
Provider Agency/Organization
Provider Name and Credentials: *
Provider Phone Number
Provider E-mail Address
Clinical Supervisor (If applicable)
Provider Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: