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PRP-Minor

Step 1 of 5

20%

PRP Minors

Date(Required)
Youth’s Name(Required)
Guardians Name(Required)
Guardians Name(Required)
Guardians’ relationship to youth(Required)

Youth's Date of Birth(Required)
Has the youth received PRP services before?(Required)
MM slash DD slash YYYY
Is the youth currently engaged in individual therapy?(Required)

PRP Minors

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)
B) Does the youth’s emotional disturbance the cause of serious dysfunction in multiple life domains (home, school, community, etc) ?(Required)
C) The impairment as a result of the youth’s emotional disturbance results in: (check all that apply)(Required)
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)
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)
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)
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)
Is there a documented crisis response plan, including both family/guardian and the primary treating provider, in progress or completed?(Required)
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)
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)
Is there evidence that the use of pharmacotherapy, if deemed appropriate, has been considered by the primary treating clinician?(Required)

PRP Minors

PRP Minors

Current Diagnosis

Please check all behaviors that apply:(Required)

PRP Minors

PRP Minors

Consent(Required)
Date(Required)

PRP Minors

Referral Authorizations(Required)

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.

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