Adult Psychiatric Rehabilitation Program (PRP)

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Referral Source Information

Initial

Re-Referral

Name of person / agency making referral:

Date of Referral:

Referral Email *

Address

Apt, suite, etc.

Country

City

State

Zip code

Mental Health Treatment Being Provided

Outpatient Mental Health Services

Inpatient Mental Health Services

Residential Treatment Center

Consumer Information

Name

Date of Birth

Age

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone Number

Medicaid #

Sexual Orientation

Heterosexual

Gay/Lesbian

Bisexual

Don’t Know

Decline

Something Else, Please Describe:

Sexual Orientation Description

Language Preference:

Race/Ethnicity:

Amer. Indian/Alaskan Native

Asian

White

Black/African American

Native American / Hawaiian or Other Pacific Islander

Hispanic

Non-Hispanic

Gender Identification

Male

Female

Transgender Male/Trans Man/(F to M)

Transgender Female/Trans Woman/(M to F)

Genderqueer (or gender nonconforming)

Decline

Additional Gender Category, please specify:

Access to Transportation for On Site Activities

Yes

This form must be filled out in its entirety in order to allow for medical necessity and authorization for services. Please do not add diagnoses to the form.

CATEGORY A

F20.9 Schizophrenia

F20.81 Schizophreniform Disorder

F25.1 Schizoaffective Disorder, Depressive

F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

F25.0 Schizoaffective Disorder, Bipolar Type

F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

F22 Delusional Disorder

F31.2 Bipolar I, Most Recent Manic, with Psychosis

F31.5 Bipolar I, Most Recent Depressed, w/o Psychosis

F33.3 MDD, Recurrent, With Psychotic Features

CATEGORY B

F31.4 Bipolar I, Most Recent Depressed, Severe

F31.0 Bipolar I, Most Recent Hypomanic

F31.9 Bipolar I, Most Recent Hypomanic, Unspecified

F31.13 Bipolar I, Most Recent Manic, Severe

F33.2 MDD, Recurrent Episode, Severe

F31.81 Bipolar II Disorder

F60.3 Borderline Personality Disorder

(If box is checked, answer questions below)

1. Has the individual been found not competent to stand trial or not criminally responsible and is receiving services recommended by a Maryland Department of Health Evaluator?

Yes

If yes, explain

2. Is the individual in a Maryland State psychiatric facility with a length of stay of more than 3 months who requires RRP upon discharge? (Select No, if individual is eligible for Developmental Disabilities Services)

Yes

If yes, explain

3. Is the individual eligible for full funding for Developmental Disabilities Administration services?

Yes

If yes, explain

4. Is the primary reason for the individual's impairment due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?

Yes

If yes, explain

5. Is individual currently receiving mental health treatment from a licensed mental health professional?

Yes

If yes, explain

Current Treatment

1. Does this person receive remuneration in any form from the PRP?

Yes

2. Duration of current episode of treatment provided to this individual**

Less than one month

1-3 months

4-6 months

7-12 months

More than 12 months

3. Current frequency of treatment provided to this individual:

At least 1x/week

At least 1x/2 weeks

At least 1x/month

At least 1x/3 months

At least 1x/6 months

4. Has this individual received PRP services from at least one other PRP within the past year?

Yes

Additional Services Received

Please indicate which of the following program(s) the individual is also receiving services from

1. Mobile Treatment/Assertive Community Treatment (ACT):

Not Applicable

Currently

In past 30 days

2. Inpatient Psychiatric Treatment

Not Applicable

Currently

In past 30 days

3. Residential SUD Treatment Service Level 3.3

Not Applicable

Currently

In past 30 days

4. Residential SUD Treatment Service Level 3.5

Not Applicable

Currently

In past 30 days

5. Residential SUD Treatment Service Level 3.7

Not Applicable

Currently

In past 30 days

6. Mental Health Intensive Outpatient Program (IOP)

Not Applicable

Currently

In past 30 days

7. Mental Health Partial Hospital Program

Not Applicable

Currently

In past 30 days

8. SUD Intensive Outpatient Program (IOP) Level 2.1

Not Applicable

Currently

In past 30 days

9. SUD Partial Hospitalization Program (PHP) Level 2.2

Not Applicable

Currently

In past 30 days

10. Residential Crisis

Not Applicable

Currently

In past 30 days

11. If currently in treatment in one of the services listed above, a written transition plan will be attached to this request

Primary Medical Diagnoses

Social Elements Impacting Diagnosis

None

Educational

Financial

Access to Health Care

Legal System/Crime

Primary Support

Housing Problems

Occupational

Other Psychosocial/Enviro.

Social Environment

Homelessness

Unknown

Functional Criteria

Per medical necessity criteria, at least three of the following must have been present on a continuing or intermittent basis over the past two years.

Functional Impairment(s):

Marked inability to establish or maintain competitive employment.

Marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management).

Marked inability to establish/maintain a personal support system

Deficiencies of concentration/ persistence/pace leading to failure to complete tasks.

Unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)

Marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities.

Marked inability to procure financial assistance to support community living.

Duration of Impairment(s)

Marked functional impairment has been present for less than 2 years.

Yes

Has demonstrated marked impaired functioning primarily due to a mental illness in at least three of the areas listed above at least 2 years.

Yes

Current Medications

Is the individual med compliant

Yes

Presenting Symptoms: (Please include History of Illness)

Severity of Illness

Intensity of Services to treat Illness

Criminal History

Yes

Reason for Referral

REASON FOR REFERRAL

(Indicate the areas you want the PRP to address.)

1) Self-care skills

personal hygiene

grooming

nutrition

dietary planning

food preparation

self-administration of medication

2) Social Skills

community integration activities

developing natural supports

developing linkages with and supporting the individual’s participation in community activities

3) Independent living skills

skills necessary for housing stability

community awareness

mobility and transportation skills

money management

accessing available entitlements and resources

supporting the individual to obtain and retain employment

health promotion and training

individual wellness self management and recovery

Medical Practitioner

Mental Health Practitioner

Mental Health Practitioner Name

Date

Mental Health Practitioner Signature

Reset Signature

Please sign using the mouse or your touchscreen

Clinical Supervisor Signature

Reset Signature

Please sign using the mouse or your touchscreen

Upload Current Treatment Plan

PRP Staff: Date Referral, Assertion of Need & Tx Plan Received

Screening Scheduled within 5 days?

Yes

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Patient Portal

Adult Psychiatric Rehabilitation Program (PRP)

Referral Source Information

Consumer Information

Current Treatment

Additional Services Received

Functional Criteria

Duration of Impairment(s)

Reason for Referral

Medical Practitioner

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Patient Portal

Referral Source Information

Consumer Information

Current Treatment

Additional Services Received

Functional Criteria

Duration of Impairment(s)

Reason for Referral

Medical Practitioner

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