PRP REFERRAL

Psychiatric Rehabilitation Program

Referral Form
Referral Date:

Month Day Year
Date
Client Name:
Date of Birth

Month Day Year
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 Code Phone Number
Client's Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

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

Full Time Part Time Disability Retired Unemployed Student
Highest Level of Education:
Primary Language:
Secondary Language:
REFERRAL Source: Agency
Name of Referring Provider

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

First Name Last Name Credentials
Phone #:
Fax #:
Address of Referring Agency (if not Aspire Wellness Center)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DIAGNOSIS(ES):
PRP eligibility is restricted to the following diagnoses
Schizoaffective d/o, Bipolar type

Schizoaffective d/o, Depressed type

Other Specified Schizophrenia Spectrum and other Psychotic d/o

Unspecified Schizophrenia Spectrum and other Psychotic d/o

Major Depressive d/o, Recurrent episode, Severe without Psychotic features

Major Depressive d/o, Recurrent episode, Severe with Psychotic features

Bipolar I d/o, Current/Most recent episode, Manic, Severe, without Psychotic features

Bipolar I d/o, Current/Most recent episode, Manic, Severe, with Psychotic features

Bipolar I d/o, Current/Most recent episode, Depressed, Severe, without Psychotic features

Bipolar I d/o, Current/Most recent episode, Depressed, Severe with Psychotic features

Bipolar I d/o, Current/Most recent episode, Hypomanic

Bipolar I d/o, Current/Most recent episode, Hypomanic, Unspecified

Unspecified Bipolar and Related d/o

Unspecified Bipolar and Related d/o
Client's Current Diagnosis(es)
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 REFERRAL
Other referral reason:
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

YES NO
INDIVIDUAL EXPERIENCES AT LEAST 3 of the following

Inability to maintain independent employment Social Behaviors that results in interventions by the mental health system Inability to procure financial assistance to support living in the community due to cognitive disorganization Severe inability to establish or maintain social supports Need for assistance with basic living skills
Referral Source Signature

Clear
Name

First Name Last Name Credentials
Date

Month Day Year
Date
Should be Empty:

DIAGNOSIS(ES):

SOCIAL ELEMENTS IMPACTING DIAGNOSIS: