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Child Referral PRP Form

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Referral for Psychiatric Rehabilitation Program (Child-PRP)

Referral Source Information

Consumer Information

DSM V DIAGNOSES : (A minor must have a behavioral diagnosis and be referred by a Licensed MH Professional to be eligible for PRP.)

*Explain “Other Psychosocial & Environmental elements"
(If applicable)

Professional Assertion of Need for PRP Services

My signature serves as my professional assertion that this individual meets the eligibility criteria outlined below and is expected to benefit from Psychiatric Rehabilitation Program (PRP) services based on the following: (Check all that apply)

REASON FOR REFERRAL
(Indicate the areas you want the PRP to address.)
(Check all that apply)
(Check all that apply)
(Check all that apply)
Add’l info (if needed)
Add’l info (if needed)
Add’l info (if needed)
Add’l info (if needed)
Explain:
Mental Health Practitioner
Please sign using the mouse or your touchscreen
Please sign using the mouse or your touchscreen
Attach a “Professional Assertion of Need for PRP Services” and a copy of the current Treatment Plan.
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