PRP Minor Referral

PRP REFERRAL FORM

Children & Adolescent Community Program
** Must be a Licensed Clinician to complete referral form.

If you are an interested client, professional, or partnership, please email prp@equanimityibhw.com
Referral Date*

MonthDayYear
Date
Medicaid ID*
Child's Name*
Gender*
Date of Birth*

MonthDayYear
Date
Address
County*
Parent/Guardian Name*
Parent/Guardian Phone*
Referring Provider Information

Must be a Licensed Practitioner of the Healing Arts in the State of Maryland
Agency Name*
Clinician Name*
Phone*
Email*
example@example.com
Credentials*
DSM-5 Diagnosis*
Treatment Duration*
ER Visits (past 6 months)*
Transition from Inpatient/Residential/Day Hospital

Yes
Functional Impairments Caused By Mental Health Symptoms

Check all that apply:
Significant emotional or behavioral outbursts affecting family or school*

Difficulty managing hygiene, self-care, or health routinesPoor social or peer relationshipsDifficulties with emotional regulationFrequent conflict or isolation at school/homeImpaired academic or vocational functioningSafety concerns (risk to self or others)Risk of hospitalization or loss of placementSignificant emotional or behavioral outbursts affectingfamily or school
Briefly describe symptoms, impact on functioning, and how PRP can help manage mental health challenges*

3-4 Sentences to determine need for program0/1000
Supportive Documents

Please submit the following documents when available to expediate referral process
- Mental Health Evaluation or Treatment Summary
- Medication List (if applicable)
File Upload

Cancelof
Provider Attestation
Signature*

Clear
* Please Include Credentials
Printed Name*
Date*

MonthDayYear
Date
To submit additional documents seperately or to contact support staff please send and email to prp@equanimitybhw.com.
Should be Empty:

PRP REFERRAL FORM

Referring Provider Information

Functional Impairments Caused By Mental Health Symptoms

Supportive Documents

Provider Attestation