Psychiatric Rehabilitation Program – Minors (PRP-M) | Restoration Behavioral Health Systems

Psychiatric Rehabilitation Program – Minors (PRP-M) Referral Form

PRP-Minor

Step 1 of 5

20%

PRP Minors

Date(Required)

Month

Day

Year

Youth’s Name(Required)

First Last

Guardians Name(Required)

First Last

Guardians Name(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Guardians’ relationship to youth(Required)

Mother

Father

Other

Youth's Date of Birth(Required)

Month

Day

Year

Age(Required)

Medicaid Number (if known)

Has the youth received PRP services before?(Required)

Yes

Program Name

Date of service (if known)

MM slash DD slash YYYY

Is the youth currently engaged in individual therapy?(Required)

Yes

Therapist Name

Phone

Current School

Current School address

Current Grade

Current medications(Required)

PRP Minors

For admission to the Psychiatric rehabilitation Program for Minors the youth MUST meet all of the following requirements:

A) Does the youth have a Public Behavioral Health System (PBHS) specialty mental health DSM-5 diagnosis and the youth’s impairment(s) and functional behavior can reasonably be expected to be improved or maintained by using these services?(Required)

Yes

B) Does the youth’s emotional disturbance the cause of serious dysfunction in multiple life domains (home, school, community, etc) ?(Required)

Yes

C) The impairment as a result of the youth’s emotional disturbance results in: (check all that apply)(Required)

I. A clear, current threat to the youth’s ability to be maintained in his/her customary setting, or

II. An emerging/impending risk to the safety of the youth and others, or

III. Other evidence of significant psychological or social impairments such as inappropriate social behavior causing serious problems with peer relationships and/or family members.

D) Is the youth, due to the dysfunction, at risk for requiring an out of home or residential placement or is returning from out of home or residential placement?(Required)

Yes

E) Does the youth’s condition require an integrated program of rehabilitation services to return to age appropriate development and to progress accordingly towards independent functioning and independent living skills?(Required)

Yes

F) Does the youth require a more intensive level of care and is deemed to be able to be safely maintained in the rehabilitation program and to benefit from the rehabilitation provided?(Required)

Yes

G) Does the youth require a more intensive level of care and is deemed to be able to be safely maintained in the rehabilitation program and to benefit from the rehabilitation provided?(Required)

Yes

Is there a documented crisis response plan, including both family/guardian and the primary treating provider, in progress or completed?(Required)

Yes

Is there clinical evidence that the current intensity of outpatient treatment is not sufficient to reduce the youth’s symptoms and functional behavioral impairment resulting from the mental illness and restore him/her to an appropriate functional level, or prevent clinical deterioration, or avert the need to initiate a more intensive level of care due to current risk to the youth or others?(Required)

Yes

Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting and there is clinical evidence that PRP services will be necessary to prevent clinical deterioration and support a successful transition back to the community or avert the need to initiate or continue a more intensive level of care?(Required)

Yes

Is there evidence that the use of pharmacotherapy, if deemed appropriate, has been considered by the primary treating clinician?(Required)

Yes

PRP Minors

Current Diagnosis

Axis I(Required)

Axis II(Required)

Axis III(Required)

Axis IV(Required)

Axis V(Required)

Please check all behaviors that apply:(Required)

Physically aggressive

Verbally aggressive

Hyperactive

Depressed mood

Impulsive

Running away

Frequent contact with law enforcement

Self injurious

Suicide ideation

Homicidal Ideation

Oppositional defiant

Separation anxiety

Has experienced trauma

Challenges authority

Self Care deficit

PRP Minors

Consent(Required)

I understand that I am making a referral for PRP services and said services must be authorized by Optum Md before any PRP services may begin.

Referred By (Name & credentials)(Required)

Date(Required)

Month

Day

Year

Name of Facility or Program(Required)

Program /Facility Address

Program /Facility Phone(Required)

Program /Facility Email

PRP Minors

Referral Authorizations(Required)

I agree to the referral authorization terms

Referral Authorizations

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

Typing my name below serves as my digital signature.

Digital Signature(Required)

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