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:
Format: (000) 000-0000.
Client Social Security Number
enter your 9 digit SS#
Client Medicaid #
Parent/Guardian Contact:

First NameLast Name
Relationship
Parent/Guardian Contact Number
Format: (000) 000-0000.
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?
The youth has been engaged in active, documented outpatient treatment for:
Current frequency of treatment provided to this individual:
In the past three months, how many ER visits has the youth had for psychiatric care?
Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting
Does the youth have a Targeted Case Management referral or authorization?
Has medication been considered for this youth?

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

MonthDayYear
Date
Should be Empty: