Psychiatric Rehabilitation Program Referral Form
Adult & Youth
Date
-
Month
-
Day
Year
Date
Referring Agency
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
MA#
Insurance Provider
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
For Minors
Parent/Guardian/Responsible Adult
First Name
Last Name
Address ( if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Qualifying Diagnosis for Adults
F20.0 Paranoid Schizophrenia
F31.0 Bipolar I Disorder, hypomanic
F20.1 Disorganized Schizophrenia
F31.13 Bipolar I Disorder, manic, severe
F20.2 Catatonic Schizophrenia
F31.4 Bipolar I Disorder, depressed, severe
F20.3 Undifferentiated Schizophrenia
F31.63 Bipolar I Disorder, mixed, severe, w/o psychotic features
F20.5 Residual Schizophrenia
F31.81 Bipolar II Disorder
F20.81 Schizophreniform Disorder
F31.9 Bipolar Disorder, Unspecified
F20.89 Other Schizophrenia
F33.2 MDD, recurrent, severe, w/o pyshotic features
F20.9 Schzophrenia, unspecified
F60.3 Borderline Personality Disorder
F25.0 Schizoaffective Disorder, Bipolar Type
F25.1 Schizoaffective Disorder, Depressed Type
F25.8 Other Schizoaffective Disorders
F25.9 Schizoaffective Disorder, Unspecified
For Minors: List diagnosis for minors here
Target Symptoms (check all they apply):
Anxiety/ Panic
Mood Swings
Depression
Paranoia
Self- Injurious Behavior
Homicidal Ideation
Sleep pattern disturbance
Increase risky behavior
Suicidality
Loss of interest
Stealing
Hallucinations
Concentration/forgetfulness
Isolation
Sexually Inappropriate Behavior
Change in appetite
Excessive energy
Social Withdraw
Irritability
Poor Stress Tolerance
Crying spells
Fire Setting
Lying Manipulation
Truancy
Verbal Aggression
Physical Aggression
Self-Care Deficits
Obsession/Compulsion
Hopeless/Helpless
Irritable
Referring provider, please provide 3-4 examples of why PRP services are being requested for this client. (examples of how their symptoms are impacting their daily functioning, time management skills, hygiene/grooming. organization/ task completion, support system, money management, appointment and/or medication adherence etc.)
PRP Services Requested (check all the apply)
Symptom Management
Self-Care Skills
Community Living
Activities of Daily Living
Social Skills
Goal Directed Behavior
Employment
Entitlements
1. Has the client received PRP services from another PRP within the last 6 months?
Yes
No
2. Is the client currently receiving mental health treatment?
Yes
No
3. If yes, How long has the client been seeing the provider?
4. How frequently does the client see the provider?
5. Is the client prescribed medication?
Yes
No
List all current prescription medications and how often you take them
6. ADULTS ONLY: Does the client receive SSI or SSDI?
Yes
No
7. ADULTS ONLY: Has the client experienced impaired role functioning for at least 2 years?
Yes
No
Treating Provider's Information
Treating Provider's Name
First Name
Last Name
Treating Provider's Agency
Treating Provider's Phone Number
Format: (000) 000-0000.
Treating Provider's Email
example@example.com
Date
-
Month
-
Day
Year
Date
Referring Mental health Provider's Information
Name
First Name
Last Name
Credentials
NPI#
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date
-
Month
-
Day
Year
Date
* Referring Mental Mealth provider ONLY!
If provisionally licensed (LMSW or LGPC), have the referral form signed by your current Licensed Clinical Supervisor.
Supervisor's Name
First Name
Last Name
Supervisor's Credentials
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: