PRP Adult Referral Form

To efficiently process referrals, please fill out this form in its entirety, sign, and date. Also include required documents listed below.

Date of Referral

Date

Client Name

Date of Birth

Date

Primary Mental Health Diagnosis (Must meet this requirement)

Gender

Race

SS

Address

Phone Number

Format: (000) 000-0000.

Guardian Name & Phone Number (If Applicable)

Format: (000) 000-0000.

SSI/SSDI Amount

Medicaid ID

Referral Source

Transition from Inpatient/Residential/Day Hospital ? (Y/N)

Number of ER visits in past 6 months

Additional Diagnoses

How often do they receive services with provider?

Duration of provider relationship

Areas of Functional Impairment for at least two years: (Check at least three to meet eligibility)

Briefly summarize the need for PRP services to include examples of how mental health symptoms impact client functioning

I am Recommending/Ordering Psychiatric Rehabilitation Services based on the Individual's Mental Health Diagnosis and the above listed functional improvements needs.

Referring Provider Signature Credentials

Date

Referring Provider Printed Name

Date of Signature

Date

Provider Phone Number

Format: (000) 000-0000.

Provider Email Address

example@example.com

Please upload any relevant clinical documentation (med list, eval, etc).

EQUANIMITY

Referring Provider Information