Youth PRP Referral Form for Mid Shore

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PRP Referrals Must be completed by the therapist referring the participant

电子邮件地址 *

Date of Referral *

年

月

日

Participant Name *

Date of Birth *

Age: *

Race *

Sex at Birth *

Gender Identity and Preferred Pronouns *

Home Address *

County *

Caroline

Dorchester

Kent

Queen Annes

Talbot

Contact Number *

Medicaid Number *

Email Address *

Parent/Guardian Name (If Applicable) *

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 *

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

Primary Diagnosis *

Additional Diagnosis

Has the Participant Been Active in Treatment? *

Yes

必填

Length of Treatment *

Has Medication Been Prescribed to Support Mental Health? *

Yes

必填

If Yes, Please List the Name of the Prescriber

Risk

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

Yes

必填

If Yes, Please Explain *

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

Yes

必填

If Yes, Please Explain *

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

必填

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 Crystal Miller directly at: cmiller@wraparoundmd.com

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