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 * 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 Previous Next 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 Previous Next 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 Previous Next 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 Previous Next 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: Symptom of Priority Population diagnosis: Paranoia Impairment impacting Functioning: Paranoia results in being suspicious of others. 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. 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 Previous Next 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 Previous Next Mental Health Practitioner First Name of person / agency making referral: Last Name of person / agency making referral: Please provide the NPI# of the person or agency making referral (if applicable) 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 Previous Next
