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Outpatient Mental Health Center
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Individual And Family Therapy
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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
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
ADULT PRP REFERRAL
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YOUTH PRP REFERRAL(Age 5-17)
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Full Name
*
Email
*
Phone No
*
Location
Message
*
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YOUNG PRP (Age 5-17)
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Your Email
Participant Name
*
Age
*
Select Race
*
American Indian
African American
Alaska Native
Asian
Black
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Native Hawaiian
Other Pacific Islander
Two or More Races
Others
Zip Code
*
Home Address
*
Medicaid Number
*
Please Select State
*
Maryland
Alabama
Alaska
Arizona
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Colorado
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District of Columbia
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
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Vermont
Virgin Islands (U.S. Territory)
Virginia pen_spark
Washington
West Virginia
Wisconsin
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Parent/Guardian Name (If Applicable)
Please Select Jurisdiction/County
*
Baltimore City
Baltimore County
Alleghany County
Anne Arundel County
Carroll County
Frederick County
Harford County
Howard County
Date Of Referral
*
Date of Birth
*
Sex at Birth
*
Please Select
*
Male
Female
City
*
Address 2
Contact Number
*
Email
Gender Identity and Preferred Pronouns, Please Select
*
She/Her/Hers
He/Him/His
They/Them/TheirsOther
REFERRING THERAPIST INFORMATION
Name and Credentials of Therapist
*
If LMSW or LPGC, Please Provide Name and Credentials of Supervisor
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Supervisor Name
Agency Name
*
Fax Number
Supervisor Credentials
Phone Number
*
Email
CLINICAL INFORMATION
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Reason for Referrel
*
Participant's Strength and Current Resources
*
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
No
ICD-10-INFORMATION
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Primary Diagnosis
*
Has the Participant been Active in Treatment?
*
Yes
No
Additional Diagnosis
Has Medication been Prescribed to Support Mental Health?
*
Yes
No
RISK ASSESSMENT
Are there any Risks for Aggressive Behavior, Suicide, or Homicide?
*
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?
*
Yes
No
PRP Services/Referral has been Explained to Participant or Parent/Guardian of Participant?
*
Yes
No
Is the Participant Currently Enrolled/Authorized for Another PRP?
*
Yes
No
By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature
*
Agree
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Signature
*
Date
Credentials
*
Supervisor
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Provide Supervisor's Name (If Applicable)
Mental Health Professional Signature
Provide Supervisor's Credentials (If Applicable)
Submit
Adult PRP
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Your Email
Participant Name
*
Age
*
Select Race
*
American Indian
African American
Alaska Native
Asian
Black
Hispanic
Latino
Native Hawaiian
Other Pacific Islander
Two or More Races
Others
Zip Code
*
Home Address
*
Medicaid Number
*
Please Select State
*
Maryland
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico (U.S. Territory)
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (U.S. Territory)
Virginia pen_spark
Washington
West Virginia
Wisconsin
Wyoming
Parent/Guardian Name (If Applicable)
Please Select Jurisdiction/County
*
Baltimore City
Baltimore County
Alleghany County
Anne Arundel County
Carroll County
Frederick County
Harford County
Howard County
Date Of Referral
*
Date of Birth
*
Sex at Birth
*
Please Select
*
Male
Female
City
*
Address 2
Contact Number
*
Email
Gender Identity and Preferred Pronouns, Please Select
*
She/Her/Hers
He/Him/His
They/Them/TheirsOther
REFERRING THERAPIST INFORMATION
Name and Credentials of Therapist
*
If LMSW or LPGC, Please Provide Name and Credentials of Supervisor
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Supervisor Name
Agency Name
*
Fax Number
Supervisor Credentials
Phone Number
*
Email
CLINICAL INFORMATION
Reason 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?
*
OTHER
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Participant'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
No
ICD-10-INFORMATION
Please Select Primary Diagnosis
*
Select Here
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?
*
Yes
No
Has Medication Been Prescribed to Support Mental Health?
*
Yes
No
Has the Participant been Active in Treatment?
*
Yes
No
RISK ASSESSMENT
Are there any Risks for Aggressive Behavior, Suicide, or Homicide?
*
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?
*
Yes
No
PRP Services/Referral has been Explained to Participant?
*
Yes
No
Is the Participant Currently Enrolled/Authorized for Another PRP?
*
Yes
No
By signing this I acknowledge that I am referring this participant for PRP Services and this is my electronic signature
*
Agree
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Signature
*
Date
Credentials
*
Supervisor
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Provide Supervisor's Name (If Applicable)
Mental Health Professional Signature
Provide Supervisor's Credentials (If Applicable)
Submit
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Full Name
*
Phone No
*
Email
*
Message
Submit