PRP Referral
Youth
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
Guardian's Name
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Date of birth
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Month
-
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
*
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
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Clinical Information
Reason for Referral
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Other
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
Primary Diagnoses
Additional Diagnoses
Is this participant currently enrolled in care coordination with Wraparound Maryland?
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Yes
No
Unknown
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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