Uncategorized

It seems we can’t find what you’re looking for. Perhaps searching can help.

Scroll to Top

YOUNG PRP (Age 5-17)

Please enable JavaScript in your browser to complete this form.

REFERRING THERAPIST INFORMATION

If LMSW or LPGC, Please Provide Name and Credentials of Supervisor

CLINICAL INFORMATION

Has a Mental Health Assessment and Treatment Plan been Completed? If yes, a Copy will need to be Provided if Accepted into the Program.

ICD-10-INFORMATION

Has the Participant been Active in Treatment?
Has Medication been Prescribed to Support Mental Health?

RISK ASSESSMENT

Are there any Risks for Aggressive Behavior, Suicide, or Homicide?
Is the Participant Coming out of In-Patient or at Risk of Going into In-Patient?
Is the Participant Currently Enrolled in Targeted Case Management?
PRP Services/Referral has been Explained to Participant or Parent/Guardian of Participant?
Is the Participant Currently Enrolled/Authorized for Another PRP?
By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature

Supervisor

Adult PRP

Please enable JavaScript in your browser to complete this form.

REFERRING THERAPIST INFORMATION

If LMSW or LPGC, Please Provide Name and Credentials of Supervisor

CLINICAL INFORMATION

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

OTHER

Has a Mental Health Assessment and Treatment Plan Been Completed? If Yes, a Copy Will Need to Be Provided If Accepted into the Program.

ICD-10-INFORMATION

Additional Diagnosis

Is the Participant Receiving Fully Funded DDA Benefits?
Has Medication Been Prescribed to Support Mental Health?
Has the Participant been Active in Treatment?

RISK ASSESSMENT

Are there any Risks for Aggressive Behavior, Suicide, or Homicide?
Is the Participant Coming out of In-Patient or at Risk of Going into In-Patient?
Is the Participant Currently Enrolled in Targeted Case Management?
PRP Services/Referral has been Explained to Participant?
Is the Participant Currently Enrolled/Authorized for Another PRP?
By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature

Supervisor

Please enable JavaScript in your browser to complete this form.