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:*
Client Social Security Number
enter your 9 digit SS#
Client Medicaid #
Is the client on medication?*

YesNo
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?*

YesNo
Duration of current episode of treatment provided to this individual:

Less than one month2-3 months4-6 months7-12 monthsMore than 12 months
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
Is the participant currently in treatment or receiving services from one of the services listed below:

Mobile Treatment Services (MTS)/Assertive Community Treatment (ACT) -AdultAdult Targeted Case Management (TCM)InpatientMH-Residential Treatment Center (RTC)Residential SUD Treatment Level 3.3Residential SUD Treatment Level 3.5Residential SUD Treatment Level 3.7Residential SUD Treatment Level 3.7WMSUD IOPMH IOPMH PHPResidential Crisis
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?

YesNo
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)?

YesNo
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?

YesNo
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?

YesNo
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)?

YesNo
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?

YesNo
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?

YesNo
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*

Clear
Date

MonthDayYear
Date
Should be Empty: