ADULT PRP Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.LayoutYour EmailParticipant Name *Age *Select Race *American IndianAfrican AmericanAlaska NativeAsian BlackHispanicLatinoNative HawaiianOther Pacific IslanderTwo or More RacesOthersZip Code *Home Address *Medicaid Number *Please Select State *MarylandAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto Rico (U.S. Territory)Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin Islands (U.S. Territory)Virginia pen_sparkWashingtonWest VirginiaWisconsinWyomingParent/Guardian Name (If Applicable)Please Select Jurisdiction/County *Baltimore CityBaltimore CountyAlleghany CountyAnne Arundel CountyCarroll CountyFrederick CountyHarford CountyHoward CountyDate Of Referral *Date of Birth *Sex at Birth *Please Select *MaleFemaleCity *Address 2Contact Number *EmailGender Identity and Preferred Pronouns, Please Select *She/Her/Hers He/Him/His They/Them/TheirsOtherREFERRING THERAPIST INFORMATIONName and Credentials of Therapist *If LMSW or LPGC, Please Provide Name and Credentials of Supervisor LayoutSupervisor NameAgency Name *Fax NumberSupervisor CredentialsPhone Number *EmailCLINICAL INFORMATIONReason for Referrel *FUNCTIONAL IMPAIRMENTS Please check all that apply and describe at least 3 Specific Mental Health Symptoms related to The Participant's Priority Population Diagnosis and describe how they Impact the Functional Impairments Below Does the Participant Have a Marked Inability to Establish or Maintain Competitive Employment? *Does the Participant Have a Marked Inability to Perform Instrumental Activities of Daily Living (e.g., Shopping, Meal Preparation, Laundry, Basic Housekeeping, Medication Management, Transportation, and Money Management)? * Does the Participant Have a Marked Inability to Establish/Maintain a Personal Support System? *Does the Participant Have Deficiencies of Concentration/Persistence/Pace Leading to Failure to Complete Tasks? *Is the Participant Unable to Perform Self-Care (Hygiene, Grooming, Nutrition, Medical Care, Safety)? *Does the Participant Have Marked Deficiencies in Self-Direction, Shown by Inability to Plan, Initiate, Organize, and Carry Out Goal-Directed Activities? *Does the Participant Have a Marked Inability to Procure Financial Assistance to Support Community Living? *OTHERLayoutParticipant's Strength and Current Resources *What is your Goals of Requested Services * Has a Mental Health Assessment and Treatment Plan Been Completed? If Yes, a Copy Will Need to Be Provided If Accepted into the Program. *Yes NoICD-10-INFORMATIONPlease Select Primary Diagnosis *Select HereF20.0 Paranoid SchizophreniaF20.1 Disorganized SchizophreniaF20.2 Catatonic SchizophreniaF20.3 Undifferentiated SchizophreniaF20.5 Residual SchizophreniaF20.81 Schizophreniform DisorderF20.89 Other SchizophreniaF20.9 Schizophrenia, UnspecifiedF25.0 Schizoaffective Disorder, Bipolar TypeF25.1 Schizoaffective Disorder, Depressive TypeF25.8 Other Schizoaffective DisordersF25.9 Schizoaffective Disorder, UnspecifiedF22 Delusional DisordersF28 Other Psychotic DisorderF29 Unspecified PsychosisF31.2 Bipolar I Disorder, Manic, Severe w/ Psychotic ftF31.5 Bipolar I Disorder, Depressed, Severe w/ Psychotic ftF31.64 Bipolar I Disorder, Mixed, Severe w/ Psychotic ftF33.3 MDD, Recurrent, Severe w/ Psychotic ftF31.0 Bipolar I Disorder, HypomanicF31.13 Bipolar I Disorder, Manic, SevereF31.4 Bipolar I Disorder, Depressed, SevereF31.63 Bipolar I Disorder, Mixed, Severe w/o Psychotic ft.F31.81 Bipolar II DisorderF31.9 Bipolar Disorder, UnspecifiedF33.2 MDD, Recurrent, Severe, w/o Psychotic ftF60.3 Borderline Personality DisorderAdditional Diagnosis LayoutIs the Participant Receiving Fully Funded DDA Benefits? *Yes NoHas Medication Been Prescribed to Support Mental Health? *Yes NoHas the Participant been Active in Treatment? *Yes NoRISK ASSESSMENTAre there any Risks for Aggressive Behavior, Suicide, or Homicide? *Yes NoIs the Participant Coming out of In-Patient or at Risk of Going into In-Patient? *Yes NoIs the Participant Currently Enrolled in Targeted Case Management? *Yes NoPRP Services/Referral has been Explained to Participant? *Yes NoIs the Participant Currently Enrolled/Authorized for Another PRP? *Yes NoBy signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature *AgreeLayoutSignature *DateCredentials * Supervisor LayoutProvide Supervisor's Name (If Applicable)Mental Health Professional SignatureProvide Supervisor's Credentials (If Applicable)Submit
