Adult PRP Referral Form for Lower Shore

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PRP Referrals Must be completed by the therapist referring the participant

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E-post *

Date of Referral *

ÅÅÅÅ

Participant Name *

Date of Birth *

Age: *

Race *

Sex at Birth *

Gender Identity and Preferred Pronouns *

Home Address *

County

Wicomico

Worcester

Somerset

Rensa markering

Contact Number *

Medicaid Number *

Email Address *

Referring Therapist Information

Name and Credentials of Therapist *

If LMSW or LGPC Please Provide the Name and Credentials of your Supervisor

Agency Name *

Phone number *

Fax Number *

Email Address *

Clinical Information

Reason for Referral *

Functional Impairments (MUST MEET AT LEAST 3)
*

Does the participant have marked inability to establish or maintain competitive employment?

Does the participant have marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management)?

Does the participant have marked inability to establish/maintain a personal support system?

Does 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 marked inability to procure financial assistance to support community living?

Obligatorisk

Please describe at least 3 specific mental health symptoms related to the participant’s priority
population diagnosis and describe how they impact the above functional impairments:
*

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

ICD-10 Information

Category A Diagnosis *

Category B Diagnosis *

Additional Diagnosis

Is the Participant Receiving Fully Funded DDA Benefits? *

Yes

Has the Participant Been Active in Treatment? *

Yes

Obligatorisk

Length of Treatment *

Has Medication Been Prescribed to Support Mental Health? *

Yes

Obligatorisk

If Yes, Please List the Name of the Prescriber

Risk

Are There any Risks for Aggressive Behavior, Suicide or Homicide? *

Yes

Obligatorisk

If Yes, Please Explain

Is the Participant Coming Out of In-Patient or at Risk of going Into In-Patient? *

Yes

Obligatorisk

If Yes, Please Explain

Is the Participant currently enrolled in Targeted Case Management *

Yes

If participant is currently involved with Targeted Case Management. Please explain how PRP support would add to the success and ability for client to maintain in current setting *

PRP services/referral has been explained to participant or parent/guardian of participant *

Yes

Is the Participant currently Enrolled/Authorized for another PRP? *

Yes

By signing this I acknowledge that I am Referring This Participant for PRP Services and This is My Electronic Signature *

Agree

Obligatorisk

Name and Credentials *

Please note the turnaround time is 1 to 2 business days to received confirmation of receipt of referral. If you have not received confirmation of receipt please contact Zina Delancey directly at: zdelancey@wraparoundmd.com

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