PRP Referral
Adults
Provide information for the person being referred to the program.
Today's Date
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Month
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Day
Year
Date
Participant's Name
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Age of participant
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Race
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Sex at birth
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Gender Identity and Preferred Pronouns
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Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County currently residing
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Please Select
Caroline County
Dorchester County
Kent County
Queen Anne County
Somerset County
Talbot County
Wicomico County
Worcester County
Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Medicaid number
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Email
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example@example.com
REFERRING THERAPIST INFORMATION
Name and Credentials of Therapist
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If LMSW or LPGC, please provide name and credentials of supervisor
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Agency Name
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Provider NPI Number
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Reason for Referral
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FUNCTIONAL IMPAIRMENTS
Must meet 3 of the following. Select all that apply
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Does the participant have marked inability to establish or maintain competitive employment?
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)?
Does the participant have marked inability to establish/maintain a personal support system?
Does the participant have deficiencies of concentration/persistence/pace leading to failure to complete tasks?
Is the participant unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)?
Does the participant have marked deficiences in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities?
Does the participant have marked inability to procure financial assistance to support community living?
Other
Please describe at least three (3) specific mental health symptoms related to the participant’s priority population diagnosis and describe how they impact the above functional impairments:
Participant's Strength and Current Resources
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Goals of Requested Services
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Has a Mental Health Assessment and Treatment Plan been completed? If YES, a copy will need to be provided if accepted into the program.
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Yes
No
ICD-10 INFORMATION
Diagnosis - Choose all that apply.
Diagnosis - Choose all that apply.
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F20.0 Paranoid Schizophrenia
F20.1 Disorganized Schizophrenia
F20.2 Catatonic Schizophrenia
F20.3 Undifferentiated Schizophrenia
F20.5 Residual Schizophrenia
F20.81 Schizophreniform Disorder
F20.89 Other Schizophrenia
F20.9 Schizophrenia, Unspecified
F25.0 Schizoaffective Disorder, Bipolar Type
F25.1 Schizoaffective Disorder, Depressive Type
F25.8 Other Schizoaffective Disorders
F25.9 Schizoaffective Disorder, Unspecified
F22 Delusional Disorders
F28 Other Psychotic Disorder
F29 Unspecified Psychosis
F31.2 Bipolar I Disorder, Manic, Severe w/Psychotic ft
F31.5 Bipolar I Disorder, Depressed, Severe w/ Psychotic ft
F31.64 Bipolar I Disorder, Mixed, Severe w/ Psychotic ft
F33.3 MDD, Recurrent, Severre w/ Psychotic ft
F31.0 Bipolar I Disorder, Hypomanic
F31.13 Bipolar I Disorder, Manic, Severe
F31.4 Bipolar I Disorder, Depressed, Severe
F31.63 Bipolar I Disorder, Mixed, Severe w/o Psychotic ft.
F31.81 Bipolar II Disorder
F31.9 Bipolar Disorder, Unspecified
F33.2 MDD, Recurrent, Severe, w/o Psychotic ft.
F60.3 Borderline Personality Disorder
Additional Diagnoses
Is the participant receiving fully funded DDA Benefits?
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Yes
No
Has the participant been active in treatment?
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Yes
No
Length of Treatment
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Has medication been prescribed to support mental health?
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Yes
No
RISK ASSESSMENT
Are there any risks for aggressive behavior, suicide, or homicide?
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Yes
No
Is the participant coming out of in-patient or at risk of going into in-patient?
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Yes
No
Is the participant currently enrolled in Targeted Case Management?
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Yes
No
PRP serices/referral has been explained to participant or parent/guardian of participant?
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Yes
No
Is the participant currently enrolled/authorized for another PRP?
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Yes
No
By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature.
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Date
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Month
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Day
Year
Date
Credentials
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Continue
Continue
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