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CTOHS Adult Referral for PRP

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Referral for Psychiatric Rehabilitation Program (Adult-PRP)

Referral Source Information

Consumer Information

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.

(If box is checked, answer questions below)

Part 1

Part 2

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

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

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.

Duration of Impairment(s)

REASON FOR REFERRAL
(Indicate the areas you want the PRP to address.)
Mental Health Practitioner
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