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Adult PRP Referral Form for Lower Shore
PRP Referrals Must be completed by the therapist referring the participant
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* Indicates required question
Email
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Your email
Date of Referral
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MM
/
DD
/
YYYY
Participant Name
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Your answer
Date of Birth
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Your answer
Age:
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Your answer
Race
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Your answer
Sex at Birth
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Your answer
Gender Identity and Preferred Pronouns
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Your answer
Home Address
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Your answer
County
Wicomico
Worcester
Somerset
Clear selection
Contact Number
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Your answer
Medicaid Number
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Your answer
Email Address
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Your answer
Referring Therapist Information
Name and Credentials of Therapist
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Your answer
If LMSW or LGPC Please Provide the Name and Credentials of your Supervisor
Your answer
Agency Name
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Your answer
Phone number
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Your answer
Fax Number
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Your answer
Email Address
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Your answer
Clinical Information
Reason for Referral
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Your answer
Functional Impairments (MUST MEET AT LEAST 3)
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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?
Required
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:
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Your answer
Participant's Strength and Current Resources
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Your answer
Goals of Requested Services
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Your answer
Has a Mental Health Assessment and Treatment Plan Been Completed? (If Yes, A Copy Will Need to be Provided if Accepted Into the Program)
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Yes
No
ICD-10 Information
Category A Diagnosis
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Choose
Option 1
F20.0 Paranoid Schizophrenia
F20.Participant does not have a category A diagnosis1 Disorganized Schizophrenia
F20.2 Catatonic Schizophrenia
F20.3 Undifferentiated Schizophrenia
F20.5 Residual Schizophrenia
F20.81 Schizophreniform Disorder
F20.89 Other Schizophrenia
F20.9 Schizophrenia, Unspecified
F25.0 Schizoaffective Disorder, Bipolar Type
F25.1 Schizoaffective Disorder, Depressive Type
F25.8 Other Schizoaffective Disorders
F25.9 Schizoaffective Disorder, Unspecified
F22 Delusional Disorders
F28 Other Psychotic Disorder
F29 Unspecified Psychosis
F31.2 Bipolar I Disorder, Manic, Severe W/Psychotic ft
F31.5 Bipolar I Disorder, Depressed, Severe W/Psychotic ft
F31.64 Bipolar I Disorder, Mixed, Severe W/Psychotic ft
F33.3 MDD, Recurrent, Severe W/Psychotic ft
Category B Diagnosis
*
Choose
Participant Does not Have a Category B Diagnosis
F31.0 Bipolar I Disorder, Hypomanic
F31.13 Bipolar I Disorder, Manic, Severe
F31.4 Bipolar I Disorder, Depressed, Severe
F31.63 Bipolar I Disorder, Mixed, Severe W/O Psychotic ft
F31.81 Bipolar II Disorder
F31.9 Bipolar Disorder, Unspecified
F33.2 MDD, Recurrent, Severe, W/O Psychotic ft
F60.3 Borderline Personality Disorder
Additional Diagnosis
Your answer
Is the Participant Receiving Fully Funded DDA Benefits?
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Yes
No
Has the Participant Been Active in Treatment?
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Yes
No
Required
Length of Treatment
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Your answer
Has Medication Been Prescribed to Support Mental Health?
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Yes
No
Required
If Yes, Please List the Name of the Prescriber
Your answer
Risk
Are There any Risks for Aggressive Behavior, Suicide or Homicide?
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Yes
No
Required
If Yes, Please Explain
Your answer
Is the Participant Coming Out of In-Patient or at Risk of going Into In-Patient?
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Yes
No
Required
If Yes, Please Explain
Your answer
Is the Participant currently enrolled in Targeted Case Management
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Yes
No
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
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Your answer
PRP services/referral has been explained to participant or parent/guardian of participant
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Yes
No
Is the Participant currently Enrolled/Authorized for another PRP?
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Yes
No
By signing this I acknowledge that I am Referring This Participant for PRP Services and This is My Electronic Signature
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Agree
Required
Name and Credentials
*
Your answer
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
A copy of your responses will be emailed to the address you provided.
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