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Psychiatric Rehabilitation Program (PRP) Referral Form - Adults

Referrer's first name

Referrer's last name

Referral date

License

Client's Information

First name

Last name

Email

Phone

Gender

Date of birth

Race

Ethnicity

Street address

Street address line 2 (Optional)

City

State

Postal / Zip code

Medical assistance phone

Emergency Contact Information

First name

Last name

Email

Phone

Relationship

Street address

Street address line 2 (Optional)

City

State

Postal / Zip code

Pregnancy, Marital Status, Military Service, and Living Situation / Condition

Living situation / condition

Pregnancy

Please tell us your living situation and condition

When is your due date?

Military service

Marital status

How long have you served in the military?

Highest level of school completed:

Is the individual currently participatin in any of the following * Required

Mobile Treatment Services

Assertive Community Treatment (ACT)

Adult Targeted Case Management (TCM)

Inpatient

Metal Health Residential Treatment Center (RTC)

Residential SUD Treatment Level 3.3 and Higher

Substance Use Disorder Intensive Outpatient / 2.1

Mental Health Intensive Outpatient / Partial Hospitalization Program

Residential Crisis

None of the above

DSM Behavioral Diagnoses

Priority Population DSM-5 / ICD-10 Behavioral Diagnosis. Clients must have one of the diagnoses as a primary to be eligible for services.

Please select one or more of the diagnosis below

Social Elements Impacting Diagnosis (Check all that apply) * Required

Self direction problems

Problems with daily living activities

Homelessness

Housing problems (not homeless)

Financial problems

Problems related to social environment

Problems with primary support group

Eductional problems

Other psychological and environmental problems

Problems related to interaction w/ legal system

Unknown

None of the above

Reason for referral (Check all that apply) * Required

Emotional / mental illness

Employment instability

Financial instability / difficulty

Lack / self-care

Behavior / conduct problems

Legal / incarceration

Medication mismanagement / monitoring

Physical / emotional abuse

Relational conflicts

Sexual abuse

Social / interpersonal challenges

Substance abuse

Suicidal / homicidal

Problem / concentration

Homelessness / at risk of homelessness

Other

Please tell us your reason for referral

PRP Services Requested

Self-care skills (Check all that apply) * Required

Personal hygiene

Grooming

Nutrition

Dietary planning

Food preparation

Self-administration of medication

Social skills (Check all that apply) * Required

Community integration activities

Developing natural supports

Developing linkages with and supporting the individual's participation in community activities

Independent living skills (Check all that apply) * Required

Skills necessary for housing stability

Community awareness

Mobility and transportation skills

Money management

Accessing available entitlements and resources

Health promotion and training

Supporting the individual to obtain and retain employment

Individual wellness self-management and recovery

Reason for referral (Check all that apply) * Required

Linkage to community resources / community integration

Facilitating transition from more intensive services

Prevention / reduction of hospitalization or rehospitalization

Coordination of current community services

Psychiatrist Information

First name

Last name

Phone

Therapist Information

First name

Last name

Phone

Primary Care Provider Information

First name

Last name

Phone

Medical Necessity Criteria

The participant's mental illness is the cause of serious dysfunction in one or more life domains.

Please select one of the following below (Check all that apply) * Required

Home

School

Community

Symptoms and behavioral / risk behaviors (Check all that apply) * Required

Anxiety / panic

Attachment problems

Depressed

Fire setting

Homicidal ideations

Hopeless / helpless hyperactive

Impulsive

Irritable

Isolative

Lying / manipulative

Manic mood

Obsession / compulsion

Oppositional defiant

Physical aggression

Property destruction

Running away

Self-care deficit

Self-injurious behavior

Separation problems

Sexually inappropriate

Social / withdrawal

Stealing

Suicidal ideations

Trauma-related

Truancy

Verbal aggression

Other

PRP criteria-adult (Check all that apply) * Required

The nature of the individual's functional impairments and/or skills deficits can be effectively remediated through specific, focused skills-training activities designed to develop and restore or maintain independent living skills to support the individuals recovery

The individual is currently engaged in Outpatient Mental Health Treatment

Resides in a RRP (not required for all individuals)

The individual does not require a more intensive level of care

All less intensive levels of treatment have been determined to be unsafe or unsuccessful

Peer or natural support alternatives have been considered or attempted, and/or are sufficient to meet the need for specific, focused skills training to function effectively

Referrer's Information

First name

Last name

Credentials

Phone

Email

Date

Street address

Street address line 2 (Optional)

City

State

Postal / Zip code

Signature

Date assigned

Counselor's first name

Counselor's last name

Comments (Optional)

Thank you! We'll be in touch.

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info@phoenixhealthmd.com

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