PRP Referral Form (Adult)

PRP Referral Form (Adult)

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 #
Is the client on medication?
Medication Name, Dosage & Frequency:
Why are medications not part of the treatment?
ICD-10 Primary Diagnosis
CLINICAL INFORMATION
Is the client currently receiving mental health treatment from a licensed mental health professional or being referred from inpatient, mental health residential crisis, or mobile treatment services/assertive community treatment program?
Duration of current episode of treatment provided to this individual:
Current frequency of treatment provided to this individual:
Is the participant currently in treatment or receiving services from one of the services listed below:
FUNCTIONAL IMPAIRMENT(S): Medical necessity for admission to Psychiatric Rehabilitation Program services must be documented by the presence of AT LEAST THREE of the following on a continuing or intermittent basis:
1. Does the client have marked inability to establish or maintain competitive employment?
a. Describe the symptoms of the diagnosis that affect the client's functioning: (ex: Paranoia)
b. Describe how specifically, these symptoms impair the client's functioning: (ex. Paranoia results in being suspicious of others)
c. Provide specific concrete examples of THIS client's impaired function: (ex. Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.)
2. Does the client have marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management)?
a. Describe the symptoms of the diagnosis that affect the client's functioning: (ex: Paranoia)
b. Describe how specifically, these symptoms impair the client's functioning: (ex. Paranoia results in being suspicious of others)
c. Provide specific concrete examples of THIS client's impaired function: (ex. Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.)
3. Does the client have marked inability to establish/maintain a personal support system?
a. Describe the symptoms of the diagnosis that affect the client's functioning: (ex: Paranoia)
b. Describe how specifically, these symptoms impair the client's functioning: (ex. Paranoia results in being suspicious of others)
c. Provide specific concrete examples of THIS client's impaired function: (ex. Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.)
4. Does the client have deficiencies of concentration/ persistence/pace leading to failure to complete tasks?
a. Describe the symptoms of the diagnosis that affect the client's functioning: (ex: Paranoia)
b. Describe how specifically, these symptoms impair the client's functioning: (ex. Paranoia results in being suspicious of others)
c. Provide specific concrete examples of THIS client's impaired function: (ex. Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.)
5. Is client unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)?
a. Describe the symptoms of the diagnosis that affect the client's functioning: (ex: Paranoia)
b. Describe how specifically, these symptoms impair the client's functioning: (ex. Paranoia results in being suspicious of others)
c. Provide specific concrete examples of THIS client's impaired function: (ex. Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.)
6. Does the client have marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities?
a. Describe the symptoms of the diagnosis that affect the client's functioning: (ex: Paranoia)
b. Describe how specifically, these symptoms impair the client's functioning: (ex. Paranoia results in being suspicious of others)
c. Provide specific concrete examples of THIS client's impaired function: (ex. Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.)
7. Does the client have marked inability to procure financial assistance to support community living?
a. Describe the symptoms of the diagnosis that affect the client's functioning: (ex: Paranoia)
b. Describe how specifically, these symptoms impair the client's functioning: (ex. Paranoia results in being suspicious of others)
c. Provide specific concrete examples of THIS client's impaired function: (ex. Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.)
LICENSCED MENTAL HEALTH PROFESSIONAL PROVDING REFERRAL:
Provider Agency/Organization Name:
Provider Name and Credentials:
Provider Phone Number
Provider E-mail Address
Clinical Supervisor (If applicable)
Provider Signature
Date

MonthDayYear
Date
Should be Empty: