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Youth PRP Referral Form for Baltimore
PRP Referrals Must be completed by the therapist referring the participant
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Email
*
Your email
Date of Referral
*
MM
/
DD
/
YYYY
Participant Name
*
Your answer
Date of Birth
*
Your answer
Age:
*
Your answer
Race
*
Your answer
Sex at Birth
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Your answer
Gender Identity and Preferred Pronouns
*
Your answer
Home Address
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Your answer
Contact Number
*
Your answer
Medicaid Number
*
Your answer
Email Address
*
Your answer
Parent/Guardian Name (If Applicable)
*
Your answer
Referring Therapist Information
Name and Credentials of Therapist
*
Your answer
If LMSW or LGPC Please Provide the Name and Credentials of your Supervisor
Your answer
Agency Name
*
Your answer
Phone number
*
Your answer
Fax Number
*
Your answer
Email Address
*
Your answer
Clinical Information
Reason for Referral
*
Your answer
Participant's Strength and Current Resources
*
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)
*
Yes
No
ICD-10 Information
Primary Diagnosis
*
Your answer
Additional Diagnosis
Your answer
Has the Participant Been Active in Treatment?
*
Yes
No
Required
Length of Treatment
*
Your answer
Has Medication Been Prescribed to Support Mental Health?
*
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?
*
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
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
*
Your answer
PRP services/referral has been explained to participant or parent/guardian of participant
*
Yes
No
Is the Participant currently Enrolled/Authorized for another PRP?
*
Yes
No
By signing this I acknowledge that I am Referring This Participant for PRP Services and This is My Electronic Signature
*
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 Tonya Kline directly at:
tkline@wraparoundmd.com
Send me a copy of my responses.
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