Psychiatric Rehabilitation Program (PRP)

The Crossroads provides Psychiatric Rehabilitation Program (PRP) services to adults ages 18 and older living with mental health and behavioral health challenges that affect emotional wellness, independence, and daily functioning.

We provide individualized support to help participants develop coping skills, improve community functioning, access supportive resources, and work toward personal recovery and wellness goals.

Our program also supports individuals experiencing co-occurring substance use disorders, developmental or intellectual disabilities, physical health conditions, and other challenges that may impact overall functioning and quality of life.

Our services are designed to help individuals:

• Strengthen coping and emotional regulation skills
• Improve independent living and community functioning
• Access healthcare services and community resources
• Build social and interpersonal skills
• Develop wellness and recovery goals
• Strengthen support systems and coordination of care

Eligibility

Individuals may be eligible for PRP services if they:

• Have active Maryland Medicaid coverage or are dual eligible for Medicare and Medicaid
• Meet medical necessity criteria for PRP services
• Are willing to actively participate in services
• Are receiving, seeking, or willing to participate in mental health treatment services

Benefits of PRP Services

• Strengthen coping and independent living skills
• Build a support system to help achieve personal goals
• Improve community functioning and emotional wellness
• Access healthcare services and community resources
• Develop individualized rehabilitation goals and wellness plans
• Improve overall quality of life

How to Get Started

1. A referral for PRP services is submitted by a licensed mental health provider.
2. An initial face-to-face assessment is completed by a Rehabilitation Specialist to determine eligibility and willingness to participate in services.
3. Authorization for services is completed prior to the start of services.
4. Once approved, services are initiated within ten (10) business days.

Once received, a member of our team will contact the individual or referral source to discuss eligibility, next steps, and scheduling.

Begin Your Journey Toward Wellness and Recovery Today

Complete the PRP referral form below or download the referral form here to begin the referral process.

Official referrals for PRP services must be submitted by a licensed mental health provider. However, individuals, family members, caregivers, hospitals, community organizations, and other support systems are welcome to contact our team for information and assistance with getting connected to services.

Completed referral forms and inquiries may be submitted to:

Email: info@thecrossroadsllc.com

Phone: (410) -710-1052

Fax: (443) -898-4074

Or fill it out below.

1

Step 1 Referral Source Information

2

Step 2 Consumer Information

3

Step 3 Clinical Information

4

Step 4 Additional Services Received

5

Step 5 Functional Criteria

6

Step 6 Reason for Referral

7

Step 7 Mental Health Practitioner

0%

Referral Source Information

Initial

Re-Referral

First Name of person / agency making referral:

Last Name of person / agency making referral:

Date of Referral:

Referral Email *

Referring Agency/Person’s Phone Number

Referring Agency/Person’s Phone Number

Address

street address

Unit number

Apt/Suite/Room/Unit

City

State

Select an Option

• Alabama
• Alaska
• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• District of Columbia
• Florida
• Georgia
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kansas
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• South Carolina
• South Dakota
• Tennessee
• Texas
• Utah
• Vermont
• Virginia
• Washington
• West Virginia
• Wisconsin
• Wyoming

Zip Code

Mental Health Treatment Being Provided

Outpatient Mental Health Services

Inpatient Mental Health Services

Residential Treatment Center

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Consumer Information

First Name

Last Name

Date of Birth

Age

Address

Apt/Suite/Room/Unit

City

State

Select an Option

• Alabama
• Alaska
• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• District of Columbia
• Florida
• Georgia
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kansas
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• South Carolina
• South Dakota
• Tennessee
• Texas
• Utah
• Vermont
• Virginia
• Washington
• West Virginia
• Wisconsin
• Wyoming

Phone Number

Please include country code 1 for U.S.

Medicaid #

Language Preference

Sexual Orientation

Heterosexual

Gay/Lesbian

Bisexual

Don’t Know

Decline

Something Else

Race/Ethnicity

Amer. Indian/Alaskan Native

Asian

White

Black/African American

Native American / Hawaiian or Other Pacific Islander

Hispanic

Non-Hispanic

Gender Identification

Male

Female

Transgender Male/Trans Man/(F to M)

Transgender Female/Trans Woman/(M to F)

Genderqueer (or gender nonconforming)

Decline

Additional Gender Category

Access to Transportation for On Site Activities

Yes

No

This form must be filled out in its entirety in order to allow for medical necessity and authorization for services. Please do not add diagnoses to the form.

Category A

F20.81 Schizophreniform Disorder

F25.1 Schizoaffective Disorder, Depressive

F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

F25.0 Schizoaffective Disorder, Bipolar Type

F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

F22 Delusional Disorder

F31.2 Bipolar I, Most Recent Manic, with Psychosis

F31.5 Bipolar I, Most Recent Depressed, w/o Psychosis

F33.3 MDD, Recurrent, With Psychotic Features

Category B

F31.0 Bipolar I, Most Recent Hypomanic

F31.9 Bipolar I, Most Recent Hypomanic, Unspecified

F31.13 Bipolar I, Most Recent Manic, Severe

F33.2 MDD, Recurrent Episode, Severe

F31.81 Bipolar II Disorder

F60.3 Borderline Personality Disorder

F42 Obsessive Compulsive Disorder (OCD)

F43.10, F43.11, F43.12 Post Traumatic Stress Disorder (PTSD)

F41.0 Panic Disorder

1. Has the individual been found not competent to stand trial or not criminally responsible and is receiving services recommended by a Maryland Department of Health Evaluator?

Yes

No

If yes, explain

2. Is the individual in a Maryland State psychiatric facility with a length of stay of more than 3 months who requires RRP upon discharge? (Select No, if individual is eligible for Developmental Disabilities Services)

Yes

No

If yes, explain

3. Is the individual eligible for full funding for Developmental Disabilities Administration services?

Yes

No

If yes, explain

4. Is the primary reason for the individual's impairment due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?

Yes

No

If yes, explain

5. Is individual currently receiving mental health treatment from a licensed mental health professional?

Yes

No

If yes, explain

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1. Is the participant receiving outpatient mental health services?

Yes

No

2. Is the licensed mental health provider enrolled as a provider in the Medicaid program?

Yes

No

3. Has an individual treatment plan/individualized rehabilitation plan been completed?

Yes

No

4. Is individual currently receiving mental health treatment from a licensed mental health professional?

Yes

No

If yes, Please provide supervisors name who must be LCSW-C or LCPC-C with your governing Board

5. Is this person in some way paid by the PRP program or receiving other benefits from the PRP program?

Yes

No

6. Duration of current episode of treatment provided to this individual

1-3 months

4-6 months

7-12 months

More than 12 months

7. Current frequency of treatment provided to this individual:

At least 1 time per 2 weeks

At least 1 time per month

At least 1 time per 3 months

At least 1 time per 6 months

8. Has this individual received PRP services from at least one other PRP within the past year?

Yes

No

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Please indicate which of the following program(s) the individual is also receiving services from

1. Mobile Treatment/Assertive Community Treatment (ACT)

Not Applicable

Currently

In past 30 days

2. Inpatient Psychiatric Treatment

Not Applicable

Currently

In past 30 days

3. Residential SUD Treatment Service Level 3.3

Not Applicable

Currently

In past 30 days

4. Residential SUD Treatment Service Level 3.5

Not Applicable

Currently

In past 30 days

5. Residential SUD Treatment Service Level 3.7

Not Applicable

Currently

In past 30 days

6. Mental Health Intensive Outpatient Program (IOP)

Not Applicable

Currently

In past 30 days

7. Mental Health Partial Hospital Program

Not Applicable

Currently

In past 30 days

8. SUD Intensive Outpatient Program (IOP) Level 2.1

Not Applicable

Currently

In past 30 days

9. SUD Partial Hospitalization Program (PHP) Level 2.2

Not Applicable

Currently

In past 30 days

10. Residential Crisis

Not Applicable

Currently

In past 30 days

11. If currently in treatment in one of the services listed above, a written transition plan will be attached to this request

Primary Medical Diagnoses

Social Elements Impacting Diagnosis

Educational

Financial

Access to Health Care

Legal System/Crime

Primary Support

Housing Problems

Occupational

Other Psychosocial/Enviro.

Social Environment

Homelessness

Unknown

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Per medical necessity criteria, at least three of the following must have been present on a continuing or intermittent basis over the past two years.

Example

To understand what is being requested for each of the functional impairments below, a generalized example of a response is provided here:

1. Symptom of Priority Population diagnosis: Paranoia
2. Impairment impacting Functioning: Paranoia results in being suspicious of others.
3. Example of impaired function: Last week he would not get on the bus because he thought the driver was out to get him. He started yelling at the bus driver.
4. If your answer is “YES” to the questions below, please answer the functional criteria questions:

Marked inability to establish or maintain competitive employment.

Yes

No

Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning

Describe how, specifically, these symptoms impair the participant's functioning

Provide specific concrete examples of THIS participant's impaired function

Marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management).

Yes

No

Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning

Describe how, specifically, these symptoms impair the participant's functioning

Provide specific concrete examples of THIS participant's impaired function

Marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities.

Yes

No

Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning

Describe how, specifically, these symptoms impair the participant's functioning

Provide specific concrete examples of THIS participant's impaired function

Marked inability to establish/maintain a personal support system.

Yes

No

Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning

Describe how, specifically, these symptoms impair the participant's functioning

Provide specific concrete examples of THIS participant's impaired function

Deficiencies of concentration/ persistence/pace leading to failure to complete tasks.

Yes

No

Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning

Describe how, specifically, these symptoms impair the participant's functioning

Provide specific concrete examples of THIS participant's impaired function

Unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)

Yes

No

Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning

Describe how, specifically, these symptoms impair the participant's functioning

Provide specific concrete examples of THIS participant's impaired function

Marked inability to procure financial assistance to support community living.

Yes

No

Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning

Describe how, specifically, these symptoms impair the participant's functioning

Provide specific concrete examples of THIS participant's impaired function

Duration of Impairment(s)

Has demonstrated marked functional impairment primarily due to a mental illness for at least two years.

Yes

No

Current Medications (Please include dose, route and frequency)

Why is ongoing outpatient treatment not sufficient to address concerns? (i.e. How could PRP services benefit the individual?)

Criminal History

Yes

No

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Self-care skills

personal hygiene

grooming

nutrition

dietary planning

food preparation

self-administration of medication

Social Skills

community integration activities

developing natural supports

developing linkages with and supporting the individual’s participation in community activities

Independent living skills

community awareness

mobility and transportation skills

money management

accessing available entitlements and resources

supporting the individual to obtain and retain employment

health promotion and training

individual wellness self management and recovery

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Mental Health Practitioner

First Name of Mental Health Practitioner:

Last Name of Mental Health Practitioner:

Please provide the NPI# of the Mental Health Practitioner

Date

Mental Health Practitioner Signature

Clear Undo Redo

Upload a copy of the current Treatment Plan.

Attach File

No Choosen File

(Max 2 MB)

PRP Staff: Date Referral, Assertion of Need & Tx Plan Received

Screening Scheduled within 5 days?

Yes

No

Submit

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