High Hopes Psychiatric Rehabilitation Program Referral
Address: 415 E 33rd St, Baltimore, MD 21218
Phone: (410) 435-0469
Email: https://highhopesllc.org
To efficiently process referrals, please fill out this form in its entirety, sign, and date. Also include required documents listed below.
Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name:
*
First Name
Last Name
DOB:
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender:
Race:
SS#:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Guardian Name & Phone Number (If Applicable):
SSI/SSDI Amount:
Medicaid ID#:
*
Referring Agency:
*
Documentation to Include with Referral:
Current Medication List (Required)
Mental Health Assessment
SSI/SSDI Documentation (If Applicable)
Transition from Inpatient/Residential/Day Hospital:
Please Select
Yes
No
ER Visits (past 6 months)
Please Select
None
1
2
3 or more
Client Diagnosis:
Category A:
Please Select
F20.0 Paranoid schizophrenia
F20.81 Schizophreniform disorder
F25.1 Schizoaffective disorder, depressive type
F31.2 Bipolar I disorder, current episode manic without psychotic features
F20.1 Disorganized schizophrenia
F20.89 Other schizophrenia
F25.8 Other schizoaffective disorders
F31.5 Bipolar I disorder, current episode manic with psychotic features
F20.2 Catatonic schizophrenia
F20.9 Schizophrenia, unspecified
F25.9 Schizoaffective disorder, unspecified
F31.64 Bipolar I disorder, current episode depressed, severe with psychotic features
F20.3 Undifferentiated schizophrenia
F22.0 Delusional disorder
F28.0 Other specified schizophrenia spectrum and other psychotic disorder
F33.3 Major depressive disorder, recurrent, severe with psychotic features
F20.5 Residual schizophrenia
F25.0 Schizoaffective disorder, bipolar type
F29.0 Unspecified psychosis not due to a substance or known physiological condition
Category B:
Please Select
F31.0 Bipolar I disorder, current episode hypomanic
F31.4 Bipolar I disorder, current episode depressed, moderate or severe without psychotic features
F31.81 Bipolar II disorder
F60.3 Borderline personality disorder
F31.13 Bipolar I disorder, current episode manic, severe, without psychotic features
F31.63 Bipolar I disorder, current episode mixed, severe, with psychotic features
F33.2 Major depressive disorder, recurrent, severe without psychotic features
F31.9 Bipolar disorder, unspecified
Additional Diagnoses:
Frequency of Treatment Episode:
Please Select
Once a week
Twice a week
Once, Bi-weekly
Twice, Bi-weekly
Once a month
Twice a month
Duration of Episode:
Less than 6 months
6 months-1 year
1 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 employment
Marked inability to perform instrumental activities of daily living
Marked inability to establish and maintain a personal support system
Marked or frequent deficiencies of concentration, persistence of pace leading to task failure
Marked inability to perform or maintain self-care
Marked deficiencies in self-direction to carry out goal directed activities
Marked inability to procure financial assistance to support community living
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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:
Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Printed Name:
First Name
Last Name
Date:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Phone Number:
Format: (000) 000-0000.
Provider E-mail Address:
example@example.com
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