PRP Referral (ADULT) PRP (Adult) 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)Baltimore CityCarolineDorchesterKentQueen AnneSomersetTalbotWicomicoWorcesterContact Number(Required)Medicaid Number(Required) Email(Required) 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)FUNCTIONAL IMPAIRMENTSMust meet 3 of the following. Select all that apply. Press "Control" to choose multiple(Required)Does the participant have marked inability to establish or maintain competitive employment?Does the participant have marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management)?Does the participant have marked inability to establish/maintain a personal support system?Does participant have deficiencies of concentration/ persistence/pace leading to failure to complete tasks?Is the participant unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)?Does the participant have marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities?Does the participant have marked inability to procure financial assistance to support community living?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)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 INFORMATIONDiagnosis - Choose all that apply. Use control key to select multiple(Required)F20.0 Paranoid SchizophreniaF20.1 Disorganized SchizophreniaF20.2 Catatonic SchizophreniaF20.3 Undifferentiated SchizophreniaF20.5 Residual SchizophreniaF20.81 Schizophreniform DisorderF20.89 Other SchizophreniaF20.9 Schizophrenia, UnspecifiedF25.0 Schizoaffective Disorder, Bipolar TypeF25.1 Schizoaffective Disorder, Depressive TypeF25.8 Other Schizoaffective DisordersF25.9 Schizoaffective Disorder, UnspecifiedF22 Delusional DisordersF28 Other Psychotic DisorderF29 Unspecified PsychosisF31.2 Bipolar I Disorder, Manic, Severe w/Psychotic ftF31.5 Bipolar I Disorder, Depressed, Severe w/ Psychotic ftF31.64 Bipolar I Disorder, Mixed, Severe w/ Psychotic ftF33.3 MDD, Recurrent, Severre w/ Psychotic ftF31.0 Bipolar I Disorder, HypomanicF31.13 Bipolar I Disorder, Manic, SevereF31.4 Bipolar I Disorder, Depressed, SevereF31.63 Bipolar I Disorder, Mixed, Severe w/o Psychotic ft.F31.81 Bipolar II DisorderF31.9 Bipolar Disorder, UnspecifiedF33.2 MDD, Recurrent, Severe, w/o Psychotic ft.F60.3 Borderline Personality DisorderAdditional Diagnoses Is the participant receiving fully funded DDA Benefits?(Required) Yes No 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)
