PRP REFERRAL

Psychiatric Rehabilitation Program

Referral Form

(MUST BE COMPLETED BY A THERAPIST)
Referral Date:

MonthDayYear
Date
Client Name:
Date of Birth

MonthDayYear
Date
SS#:
Gender Identity
Race(s):
Medical Assistance #
(if uninsured, please note if an application is pending)
Legal Guardian (if minor or designated legal guardian):
Relationship (to minor or individual)
Phone Number

Area CodePhone Number
Client's Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian Address (if different from above):
Marital Status:
Employment Status

Full TimePart TimeDisabilityRetiredUnemployedStudent
Highest Level of Education:
Primary Language:
Secondary Language:
REFERRAL Source: Agency
Name of Referring Provider

First NameLast NameCredentials
Referring provider NPI #
Does your practice accept Medicaid

YesNo
Supervisor's Name/Licensure/Credentials: applicable)
Name of Supervisor (if applicable)

First NameLast NameCredentials
Referrring Agency Phone #:
Referring Agency Fax #:
Address of Referring Agency (if not Aspire Wellness Center)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DIAGNOSIS(ES):
PRP eligibility is restricted to the following diagnoses
Please check Qualifying Diagnosis

F20.0 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 disordersF22 Delusional DisorderF28 Other psychotic disorderF 29 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, severe w/psychotic ftF31.0 Bipolar I disorder, hypomanicF31.13 Bipolar I disorder, manic, severeF31.4 Bipolar I disorder, depressed, severeF31.63 Bipolar disorder, mixed, severe w/o psychoticF31.81 Bipolar II disorderF31.9 Bipolar disorder, unspecifiedF33.2 MDD, recurrent, severe w/o psychotic ftF60.3 Borderline personality disorder
Client's Additional Diagnosis(es)
Please include ICD-10 codes and description
Behavioral Diagnoses Description
MEDICATIONS/DOSAGE/PRESCRIBING PHYSICIAN
SOCIAL ELEMENTS IMPACTING DIAGNOSIS:
Educational
Problems Related to Interactions with Legal System/Crime
Housing Problems (not homelessness)
Problems with Access to Healthcare Services
Primary Support Group
Occupational Problems
Problems Related to the Social Environment
Other Psycho-social and Environmental Problems
Reason for PRP Referral
Presenting Symptoms/Comments (include hx of SI/HI):
This Individual has a serious mental illness which has required the intervention of the Public Mental Health System in the last two years

YESNO
INDIVIDUAL EXPERIENCES AT LEAST 3 of the following

Inability to maintain independent employmentSocial Behaviors that results in interventions by the mental health systemInability to procure financial assistance to support living in the community due to cognitive disorganizationSevere inability to establish or maintain social supportsNeed for assistance with basic living skills
Please provide clinical rationale for each issue checked above
Referral Source Signature

Clear
Name

First NameLast NameCredentials
Date

MonthDayYear
Date
Should be Empty:

DIAGNOSIS(ES):

SOCIAL ELEMENTS IMPACTING DIAGNOSIS: