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Services
Outpatient Mental Health Center
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Menu
Home
Services
Outpatient Mental Health Center
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Psychotherapy
Individual And Family Therapy
About Us
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PRP Referrals
Special Program Event
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Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
Psychotherapy
Individual And Family Therapy
About Us
Contact Us
PRP Referrals
Special Program Event
Menu
Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
Psychotherapy
Individual And Family Therapy
About Us
Contact Us
PRP Referrals
Special Program Event
Sign In
Sign up
Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
Psychotherapy
Individual And Family Therapy
About Us
Contact Us
PRP Referrals
Special Program Event
Menu
Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
Psychotherapy
Individual And Family Therapy
About Us
Contact Us
PRP Referrals
Special Program Event
Sign In
Sign up
Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
Psychotherapy
Individual And Family Therapy
About Us
Contact Us
PRP Referrals
Special Program Event
Menu
Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
Psychotherapy
Individual And Family Therapy
About Us
Contact Us
PRP Referrals
Special Program Event
Sign In
Sign up
Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
Psychotherapy
Individual And Family Therapy
About Us
Contact Us
PRP Referrals
Special Program Event
Menu
Home
Services
Outpatient Mental Health Center
Intensive Outpatient Program
Psychiatric Rehabilitation Program
Medication Management Services
Substance Abuse Disorder
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YOUNG PRP (Age 5-17)
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REFERRING THERAPIST INFORMATION
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CLINICAL INFORMATION
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Has a Mental Health Assessment and Treatment Plan been Completed? If yes, a Copy will need to be Provided if Accepted into the Program.
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ICD-10-INFORMATION
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Primary Diagnosis
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Additional Diagnosis
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RISK ASSESSMENT
Are there any Risks for Aggressive Behavior, Suicide, or Homicide?
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Participant Name
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Date Of Referral
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Date of Birth
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Sex at Birth
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Please Select
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Address 2
Contact Number
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Email
Gender Identity and Preferred Pronouns, Please Select
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REFERRING THERAPIST INFORMATION
Name and Credentials of Therapist
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Supervisor Name
Agency Name
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Fax Number
Supervisor Credentials
Phone Number
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CLINICAL INFORMATION
Reason for Referrel
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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?
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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)?
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Does the Participant Have a Marked Inability to Establish/Maintain a Personal Support System?
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Does the Participant Have Deficiencies of Concentration/Persistence/Pace Leading to Failure to Complete Tasks?
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Is the Participant Unable to Perform Self-Care (Hygiene, Grooming, Nutrition, Medical Care, Safety)?
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Does the Participant Have Marked Deficiencies in Self-Direction, Shown by Inability to Plan, Initiate, Organize, and Carry Out Goal-Directed Activities?
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Does the Participant Have a Marked Inability to Procure Financial Assistance to Support Community Living?
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Participant's Strength and Current Resources
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What is your Goals of Requested Services
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Has a Mental Health Assessment and Treatment Plan Been Completed? If Yes, a Copy Will Need to Be Provided If Accepted into the Program.
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Yes
No
ICD-10-INFORMATION
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F20.0 Paranoid Schizophrenia
F20.1 Disorganized Schizophrenia
F20.2 Catatonic Schizophrenia
F20.3 Undifferentiated Schizophrenia
F20.5 Residual Schizophrenia
F20.81 Schizophreniform Disorder
F20.89 Other Schizophrenia
F20.9 Schizophrenia, Unspecified
F25.0 Schizoaffective Disorder, Bipolar Type
F25.1 Schizoaffective Disorder, Depressive Type
F25.8 Other Schizoaffective Disorders
F25.9 Schizoaffective Disorder, Unspecified
F22 Delusional Disorders
F28 Other Psychotic Disorder
F29 Unspecified Psychosis
F31.2 Bipolar I Disorder, Manic, Severe w/ Psychotic ft
F31.5 Bipolar I Disorder, Depressed, Severe w/ Psychotic ft
F31.64 Bipolar I Disorder, Mixed, Severe w/ Psychotic ft
F33.3 MDD, Recurrent, Severe w/ Psychotic ft
F31.0 Bipolar I Disorder, Hypomanic
F31.13 Bipolar I Disorder, Manic, Severe
F31.4 Bipolar I Disorder, Depressed, Severe
F31.63 Bipolar I Disorder, Mixed, Severe w/o Psychotic ft.
F31.81 Bipolar II Disorder
F31.9 Bipolar Disorder, Unspecified
F33.2 MDD, Recurrent, Severe, w/o Psychotic ft
F60.3 Borderline Personality Disorder
Additional Diagnosis
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Is the Participant Receiving Fully Funded DDA Benefits?
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No
Has Medication Been Prescribed to Support Mental Health?
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Yes
No
Has the Participant been Active in Treatment?
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Yes
No
RISK ASSESSMENT
Are there any Risks for Aggressive Behavior, Suicide, or Homicide?
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Yes
No
Is the Participant Coming out of In-Patient or at Risk of Going into In-Patient?
*
Yes
No
Is the Participant Currently Enrolled in Targeted Case Management?
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Yes
No
PRP Services/Referral has been Explained to Participant?
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Yes
No
Is the Participant Currently Enrolled/Authorized for Another PRP?
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Yes
No
By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature
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