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YOUNG PRP (Age 5-17)

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Your Email

Participant Name *

Age *

Select Race *

Zip Code *

Home Address *

Medicaid Number *

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Parent/Guardian Name (If Applicable)

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Date Of Referral *

Date of Birth *

Sex at Birth *

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City *

Address 2

Contact Number *

Email

Gender Identity and Preferred Pronouns, Please Select *

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)

Adult PRP

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Participant Name *

Age *

Select Race *

Zip Code *

Home Address *

Medicaid Number *

Please Select State *

Parent/Guardian Name (If Applicable)

Please Select Jurisdiction/County *

Date Of Referral *

Date of Birth *

Sex at Birth *

Please Select *

City *

Address 2

Contact Number *

Email

Gender Identity and Preferred Pronouns, Please Select *

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 *

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)

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Full Name *

Phone No *

Email *

Message