PRP Services – Client Interest & Intake Form
Please complete this form if you are interested in Psychiatric Rehabilitation Program (PRP) services for yourself or another individual. For clients under 18, the form should be completed by a parent or legal guardian. This information will be used to help determine eligibility and begin the referral/intake process. Completing this form does not guarantee enrollment or Medicaid authorization.
PERSON COMPLETING THIS FORM
1. Full Name
First Name
Last Name
2. Relationship to Client (Self / Parent / Legal Guardian / Caregiver / Other)
3. Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
4. Phone Number
Format: (000) 000-0000.
5. Email Address
example@example.com
6. Preferred Method of Contact (Text / Phone Call / Email)
7. Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CLIENT INFORMATION
8. Client's Full Legal Name
First Name
Last Name
9. Client's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
10. Client's Age
11. Client's Gender (Optional)
12. Client's Phone Number (if different from above)
Format: (000) 000-0000.
13. Client's Home Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
14. If the client is school-aged: School Name
15. If the client is school-aged: Current Grade
INSURANCE / MEDICAID INFORMATION
16. Does the client currently have Maryland Medicaid/Medical Assistance? (Yes / No / Unsure)
Yes
No
Unsure
17. Medicaid MCO/Insurance Provider
18. Medicaid/Medical Assistance Number
19. Upload a picture of the front and back of the client's Medicaid/insurance card.
PRP & MENTAL HEALTH PROVIDER INFORMATION
20. Has the client ever received PRP services before? (Yes / No / Unsure)
Yes
No
Unsure
21. If yes, what PRP agency/provider did the client receive services through?
22. Is the client currently receiving PRP services from another provider? (Yes / No / Unsure)
Yes
No
Unsure
23. Does the client currently have a therapist or mental health provider? (Yes / No)
Yes
No
24. Therapist/Mental Health Provider Name
First Name
Last Name
25. Therapist/Provider Phone Number
Format: (000) 000-0000.
26. Therapist/Provider Email Address
example@example.com
27. How often does the client currently see their therapist/provider? (Weekly / Twice Monthly / Monthly / Other)
Back
Next
28. If the client does not currently have a therapist, would they like assistance connecting with one? (Yes / No)
Yes
No
AREAS OF SUPPORT
29. What areas would the client benefit from additional support with? Select all that apply: Confidence/Self-Esteem; Anger Management; Communication; Social Skills; School/Academic Support; Employment/Vocational Support; Behavior; Emotional Regulation; Independent Living/Life Skills; Hygiene/Self-Care; Physical Activity/Fitness; Sports/Recreation; Community Involvement; Building Healthy Relationships; Decision-Making; Other.
Confidence/Self-Esteem
Anger Management
Communication
Social Skills
School/Academic Support
Employment/Vocational Support
Behavior
Emotional Regulation
Independent Living/Life Skills
Hygiene/Self-Care
Physical Activity/Fitness
Sports/Recreation
Community Involvement
Building Healthy Relationships
Decision-Making
Other
30. Please briefly describe the primary concerns or goals for PRP services.
31. Are there any behavioral, emotional, developmental, or safety concerns the PRP team should be aware of? (Optional)
32. Are there any allergies, medical considerations, mobility limitations, or other important information we should know when providing community-based services? (Optional)
REFERRAL INFORMATION
33. How did you hear about our PRP services? (Friend/Family / Therapist / Social Media / School / Community Organization / Current Client / Other)
Friend/Family
Therapist
Social Media
School
Community Organization
Current Client
Other
34. If someone referred you, who referred you?
35. Is there anything else you would like us to know about the client or their needs?
ACKNOWLEDGMENT & CONSENT TO CONTACT
*
I understand
I give permission
38. Name of Person Completing Form
*
First Name
Last Name
39. Signature
*
40. Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
JOTFORM SETUP NOTES
• Make Client's Date of Birth, Client's Full Legal Name, contact phone number, Medicaid status, and relationship to client required fields.
• Use conditional logic so therapist/provider details only appear when the client currently has a therapist/provider.
• Show the previous PRP provider question only when "Yes" is selected for previous PRP services.
• Show school and grade questions when applicable to a school-aged client.
• If "Self" is selected for Relationship to Client, avoid requiring duplicate contact/address information.
• Configure health/insurance information and file uploads according to your organization's privacy and HIPAA requirements before collecting real client information.
Preview PDF
Submit
Should be Empty: