Psychiatric Rehabilitation Program – Adults (PRP-A) Referral Form Step 1 of 7 14% RESTORATION BEHAVIORAL HEALTH SYSTEMS PSYCHIATRIC REHABILITATION PROGRAM REFERRAL FOR SERVICESTo efficiently process referrals, please fill out this form in its entirety, sign and date.Medical Necessity Criteria* : To ensure that clients being referred to PRP services meet the medical necessity criteria as defined by COMAR we must document the individual's behavior and describe how the individual meets criteria for this service. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from a mental, behavioral, or emotional illness that results in significant functional impairments in major life activities.Referral Source Information:Date Month Day Year Referring Agency: Treating Provider Name, Title & Credentials: Treating PhoneEmail Demographic Information:Client Name Date Month Day Year AgePlease enter a number from 1 to 100.SS#MA# Gender Preference: Ethnicity/Race Primary Language Marital Status Single Married Divorced Separated Widow Partnered Veteran Yes No If yes, what is the year of discharge? Full Address, City, State, Zip Code: Homeless? Check here if Homeless If homeless, how long? Home PhoneMobile PhoneEmail Guardian(s) PhonePrimary Care Physician PhoneFaxAccommodations TTY Interpreter Sign language Ambulatory limitations None Other Other Accommodations Legal Status Adopted Parent is legal guardian Committed to DSS Custody Arrested within the last 30 days Receiving SSI or SSDI? Yes No Other Enrolled in PRP in the last yr? Yes No Employment Status Currently? Yes No Not Applicable Seeking Employment Where? Educational Status Currently enrolled? Yes No Highest Grade Complete Current School Name (if minor) Is client currently enrolled in any of the following: Mobile Treatment Assertive Community Treatment-Adult Adult Targeted Case Management (TCM Inpatient MH- Residential Treatment Center (RTC) Residential SUD Treatment Level 3.3. and higher SUD IOP/2.1 MH IOP/PHP Residential Crisis Anger Management Conflict Resolution If client is currently enrolled in any of these services, they are not eligible for PRP services, at this time.Rehabilitation Services Requested: Dietary Planning Maintain Personal Living Space Age-Appropriate Self-Care Skills Community Integration Activities Age-Appropriate Boundaries Self-Administration of Medication Maintain Personal Safety Social Skills/Peer Interaction Physical Health Anger Management Conflict Resolution Grooming Family Natural Support Issues Coping Skills Mindful Coping Strategies Assertiveness/Self-Esteem Developing Natural Supports Interaction with Peers/Authority Figures Health Promotion & Training Community Awareness/Advocacy Time Management Individual Wellness Self-Management and Recovery Facilitating transition from more intensive services School Performance Issues Access Entitlements Current TreatmentPlease list agency, type of treatment, duration of treatment, frequency of treatment, and party responsible for current inpatient and outpatient therapeutic services.Agency Name Type of Treatment Duration of Treatment Less than a month 2-3 months 4-6 months 7-12 months more than 12 month Frequency of Treatment At least 1x/week At least 1x/2 weeks At least 1x/month At least 1x/3months At least 1x/6 months Responsible Party Current TreatmentAgency Name Type of Treatment Duration of Treatment Less than a month 2-3 months 4-6 months 7-12 months more than 12 month Frequency of Treatment At least 1x/week At least 1x/2 weeks At least 1x/month At least 1x/3months At least 1x/6 months Responsible Party Current TreatmentAgency Name Type of Treatment Duration of Treatment Less than a month 2-3 months 4-6 months 7-12 months more than 12 month Frequency of Treatment At least 1x/week At least 1x/2 weeks At least 1x/month At least 1x/3months At least 1x/6 months Responsible Party 1 medication, dosage & frequency per lineCurrent Medication Client is not currently taking medication Name of MedicationDosageFrequency PLEASE NOTE: THIS PAGE MUST BE COMPLETED FOR ALL ADULT REFERRALSDiagnosis: Please indicate current DSM diagnosis (MUST HAVE ICD-10 Code) ADULTS MUST HAVE ONE OF THE FOLLOWING DIAGNOSIS FOR PRP ELIGIBILITY CONVERTED TO ICD 10 CODE295.90/F20.9 Schizophrenia 295.40/F20.81 Schizophreniform Disorder 295.70/F25.0 Schizoaffective Disorder, Bipolar Type 295.70/F25.1 Schizoaffective Disorder, Depressive Type 298.8/F28 Other Specified Schizophrenia Spectrum and Other Psychotic D/O 298.9/F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder 297.1/F22 Delusional Disorder 296.33/F33.2 Major Depressive Disorder, Recurrent Episode, Severe 296.34/F33.3 Major Depressive Disorder, Recurrent Episode, W/Psychotic Features 301.22/F21 Schizotypal Personality Disorder296.43/F31.13 Bipolar I Disorder, Current or Most Recent Episode Manic, Severe 296.44/F31.2 Bipolar I Disorder, Current or Most Recent Episode Manic Psychotic Features 296.53/F31.4 Bipolar I Disorder, Current or Most Recent Episode Depressed, Severe 296.54/F31.5 Bipolar I Disorder, Most Recent Episode Depressed, With Psychotic Features 296.40/F31.0 Bipolar I Disorder, Current or Most Recent Episode Hypomanic 296.40/F31.9 Bipolar I Disorder, Current or Most Recent Episode Hypomanic, Unspecified 296.7/F31.9 Bipolar I Disorder, Current or Most Recent Episode Unspecified 296.80/F31.9 Unspecified Bipolar and Related Disorder 296.89/F31.81 Bipolar II Disorder 301.83F60.3 Borderline Personality DisorderPRIMARY ICD 10 CODE: PRIMARY DSM V CODE: ICD 10 CODE: DSM V CODE: PER MEDICAL NECESSITY CRITERIA, AT LEAST THREE OF THE FOLLOWING MUST BE PRESENT ON A CONTINUING OR INTERMITTENT BASIS OVER THE PAST TWO YEARS. CHECK ALL THAT APPLY.Functional Impairment Areas (The impairment as a result of the participant’s mental illness 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 in inability to procure financial assistance to support community living. Based on the functional impairment areas identified above, please describe how the symptoms of the client’s diagnosis impair their functioning specifically. Please be sure to provide a few examples of the impairment caused by the symptoms that is specific to the client. Print Clinicians Name: Credentials: SignatureDate Month Day Year
