PRP Adult Referral Form

EQUANIMITY

ADULT PRP REFERRAL
To efficiently process referrals, please fill out this form in its entirety, sign, and date. Also include required documents listed below.
Date of Referral*

MonthDayYear
Date
Client Name*
Date*

MonthDayYear
Date
Primary Mental Health Diagnosis (Must meet this requirement)*
Gender*
Race*
SS*
Address
Phone Number*
Guardian Name & Phone Number (If Applicable)
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*

Less than 6 months6 months- 1 year1 year or more
Areas of Functional Impairment for at least two years: (Check at least three to meet eligibility)*

Marked inability to establish or maintain independent competitive employmentMarked inability to perform instrumental activities of daily livingMarked inability to establish and maintain a personal support systemMarked or frequent deficiencies of concentration, persistence of pace leading to task failureMarked inability to perform or maintain self-careMarked deficiencies in self-direction to carry out goal directed activitiesMarked inability to procure financial assistance to support community living
Briefly summarize the need for PRP services to include examples of how mental health symptoms impact client functioning*
Referring Provider Information

Must be a Licensed Practitioner of the Healing Arts in the State of Maryland.
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*

Clear
Date*

MonthDayYear
Date
Referring Provider Printed Name*
Date of Signature*

MonthDayYear
Date
Provider Phone Number*
Provider Email Address*
example@example.com
Please upload any relevant clinical documentation (med list, eval, etc).

Cancelof
Should be Empty:

EQUANIMITY

Referring Provider Information