PRP Referral Form

Name:*

Gender:

Marital Status:

Social Security#:*

DOB:*

mm/dd/yyyy

Age:

Race:

MA#:

Legal Guardian:

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone#:

Alt Phone#:

Email Address:

example@example.com

Employer/School:

Grade:

Referring Agency:

Contact Person:

NPI#:

Agency Address:

Phone Number:

Therapist Supervisor Name/Credentials:

Is the participant on medication?

Please explain why the client is not on medication.

Clients referred to PRP must be referred from inpatient, residential crisis, mobile treatment/assertive community treatment, mental health RTC programs, incarceration or from their treatment outpatient mental health provider.

Where is the client being referred from?

Is the participant in ongoing, active treatment with the referring provider?

Please state the last active session with the client.

Why is ongoing outpatient treatment not sufficient to address concerns?

Please explain why PRP services are needed.

Is the client employed?

Has the client been referred to supportive employment?

Explain why the client has not been referred to supportive employment.

Has the client demonstrated marked functional impairment for at least 2 years?

Functional Impairments

PLEASE PROVIDE EVIDENCE OF HOW AT LEAST 3 OF THE CONSUMER’S FUNCTIONAL IMPAIRMENTS ARE RELATED TO THE CONSUMER’S MENTAL HEALTH DIAGNOSIS AND SYMPTOMS. WHAT SYMPTOMS ARE THEY CURRENLY HAVING, AND HOW ARE THESE SYMPTOMS NEGATIVELY AFFECTING THEIR FUNCTIONAL CRITERIA?

To understand what is being requested for each of the functional impairments below, a generalized example is provided here:

1. Symptoms of Priority Population diagnosis: Paranoia

2. Impairment impacting Functioning: Paranoia results in being suspicious of others.

3. Example of impaired function: 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.

A. Does the participant have marked inability to establish or maintain competitive employment?

1A.

2A.

3A.

B. Does the participant have marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management)?

1B.

2B.

3B.

C. Does the participant have marked inability to establish/maintain a personal support system?

1C.

2C.

3C.

D. Does the participant have deficiencies of concentration/persistence/pace leading to failure to complete tasks?

1D.

2D.

3D.

E. Is the participant unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)?

1E.

2E.

3E.

F. Does the participant have marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities?

1F.

2F.

3F.

G. Does the participant have marked inability to procure financial assistance to support community living?

1G.

2G.

3G.

H. Has consideration been given to using peer support and other informal support such as family?

1H.

I. Has group therapy been tried in the past?

What is the reason this has not been tried?

J. Has targeted case management been tried?

What is the reason this has not been tried?

Primary Dx:

Secondary Dx:

Tertiary Dx:

Dx Given By:

Medications:

Medication Provider Name:

CARE AGREEMENT:

I (Therapist Name and Title) am consenting to PRP services for my (Client Name) and AGS Programs.

Therapist Name and Title:

Client Name:

Electronic Signature: (Please type Full Name & License credentials)*

Date:*

mm/dd/yyyy

Electronic Signature Agreement:*

I agree and understand that checking this box constitutes an electronic signature.

Please verify that you are human*

AGS PROGRAMS

IF NO, WE CANNOT MOVE FORWARD WITH THIS REFERRAL!

PLEASE FILL IN BELOW: