Empowerment Through - Wrap Around Maryland Inc

Your email(Required)

Date of Referral(Required)

Date of Birth(Required)

Age(Required)

Race(Required)

Sex at Birth(Required)

Gender Identity and Preferred Pronouns(Required)

Jurisdiction/County(Required)

Contact Number(Required)

Medicaid Number(Required)

Email(Required)

REFERRING THERAPIST INFORMATION

Name and Credentials of Therapist(Required)

If LMSW or LPGC, please provide name and credentials of supervisor

Agency Name(Required)

Phone Number(Required)

Fax Number(Required)

Email(Required)

CLINICAL INFORMATION

Reason for Referral(Required)

FUNCTIONAL IMPAIRMENTS

Must meet 3 of the following. Select all that apply. Press "Control" to choose multiple(Required)

Other

Please describe at least 3 specific mental health symptoms related to the participant’s priority population diagnosis and describe how they impact the above functional impairments:(Required)

Participant's Strength and Current Resources(Required)

Goals of Requested Services(Required)

ICD-10 INFORMATION

Diagnosis - Choose all that apply. Use control key to select multiple(Required)

Additional Diagnoses

Length of Treatment(Required)

If yes to medication, name of prescriber, medication, dosage, and frequency.

RISK ASSESSMENT

If yes, explain

If participant is currently involved with Targeted Case Management, please explain how PRP support would add to the success and ability for client to maintain in current setting.

Signature(Required)

Date(Required)

Credentials(Required)

PRP Referral (ADULT)

PRP (Adult)

REFERRING THERAPIST INFORMATION

CLINICAL INFORMATION

FUNCTIONAL IMPAIRMENTS

ICD-10 INFORMATION

RISK ASSESSMENT