PRP Referral (Youth) PRP (Youth) Your email(Required) Date of Referral(Required) MM slash DD slash YYYY Participant Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Age(Required) Race(Required) Sex at Birth(Required) Gender Identity and Preferred Pronouns(Required) Home Address(Required) Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Jurisdiction/County(Required)CarolineDorchesterKentQueen AnneSomersetTalbotContact Number(Required)Medicaid Number(Required) Email(Required) Parent/Guardian Name (If Applicable) REFERRING THERAPIST INFORMATIONName 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 INFORMATIONReason for Referral(Required)Participant's Strength and Current Resources(Required)Goals of Requested Services(Required)Has a Mental Health Assessment and Treatment Plan been completed? If YES, a copy will need to be provided if accepted into the program. Yes No ICD-10-INFORMATIONPrimary Diagnosis(Required) Additional Diagnoses Has the participant been active in treatment?(Required) Yes No Length of Treatment(Required) Has medication been prescribed to support mental health?(Required) Yes No If yes to medication, name of prescriber, medication, dosage, and frequency. RISK ASSESSMENTAre there any risks for aggressive behavior, suicide, or homicide?(Required) Yes No If yes, explainIs the participant coming out of in-patient or at risk of going into in-patient?(Required) Yes No If yes, explainIs the participant currently enrolled in Targeted Case Management?(Required) Yes No 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.PRP serices/referral has been explained to participant or parent/guardian of participant?(Required) Yes No Is the participant currently enrolled/authorized for another PRP?(Required) Yes No By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature(Required) Agree Signature(Required)Date(Required) MM slash DD slash YYYY Credentials(Required)
