If you are human, leave this field blank.Referral Source Information Referral Source InformationInitialRe-ReferralName of person / agency making referral:Date of Referral:Referral Email *AddressApt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeMental Health Treatment Being ProvidedOutpatient Mental Health ServicesInpatient Mental Health ServicesResidential Treatment CenterConsumer InformationNameDate of BirthAgeAddressApt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codePhone NumberMedicaid #Sexual OrientationHeterosexualGay/Lesbian BisexualDon’t Know DeclineSomething Else, Please Describe:Sexual Orientation DescriptionLanguage Preference:Race/Ethnicity:Amer. Indian/Alaskan NativeAsianWhiteBlack/African AmericanNative American / Hawaiian or Other Pacific IslanderHispanicNon-HispanicGender IdentificationMaleFemaleTransgender Male/Trans Man/(F to M)Transgender Female/Trans Woman/(M to F)Genderqueer (or gender nonconforming)DeclineAdditional Gender Category, please specify:Access to Transportation for On Site ActivitiesYesNoThis 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 AF20.9 SchizophreniaF20.81 Schizophreniform DisorderF25.1 Schizoaffective Disorder, DepressiveF29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder F25.0 Schizoaffective Disorder, Bipolar TypeF28 Other Specified Schizophrenia Spectrum and Other Psychotic DisorderF22 Delusional DisorderF31.2 Bipolar I, Most Recent Manic, with PsychosisF31.5 Bipolar I, Most Recent Depressed, w/o Psychosis F33.3 MDD, Recurrent, With Psychotic FeaturesCATEGORY BF31.4 Bipolar I, Most Recent Depressed, Severe F31.0 Bipolar I, Most Recent HypomanicF31.9 Bipolar I, Most Recent Hypomanic, UnspecifiedF31.13 Bipolar I, Most Recent Manic, SevereF33.2 MDD, Recurrent Episode, SevereF31.81 Bipolar II DisorderF60.3 Borderline Personality Disorder (If box is checked, answer questions below)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?YesNoIf yes, explain2. 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) YesNoIf yes, explain3. Is the individual eligible for full funding for Developmental Disabilities Administration services? YesNoIf yes, explain4. Is the primary reason for the individual's impairment due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?YesNoIf yes, explain5. Is individual currently receiving mental health treatment from a licensed mental health professional? YesNoIf yes, explainClinical Information1. Is the participant receiving outpatient mental health services? YesNo2. Is the licensed mental health provider enrolled as a provider in the Medicaid program?YesNo3. Has an individual treatment plan/individualized rehabilitation plan been completed? YesNo4. Is individual currently receiving mental health treatment from a licensed mental health professional?YesNoPlease provide supervisors name who must be LCSW-C or LCPC-C with your governing Board5. Is this person in some way paid by the PRP program or receiving other benefits from the PRP program?YesNo6. Duration of current episode of treatment provided to this individual**Less than one month1-3 months4-6 months7-12 monthsMore than 12 months7. Current frequency of treatment provided to this individual:At least 1x/weekAt least 1x/2 weeksAt least 1x/monthAt least 1x/3 monthsAt least 1x/6 months8. Has this individual received PRP services from at least one other PRP within the past year?YesNoAdditional Services ReceivedPlease indicate which of the following program(s) the individual is also receiving services from1. Mobile Treatment/Assertive Community Treatment (ACT): Not ApplicableCurrentlyIn past 30 days2. Inpatient Psychiatric TreatmentNot ApplicableCurrentlyIn past 30 days3. Residential SUD Treatment Service Level 3.3Not ApplicableCurrentlyIn past 30 days4. Residential SUD Treatment Service Level 3.5Not ApplicableCurrentlyIn past 30 days5. Residential SUD Treatment Service Level 3.7Not ApplicableCurrentlyIn past 30 days6. Mental Health Intensive Outpatient Program (IOP)Not ApplicableCurrentlyIn past 30 days7. Mental Health Partial Hospital ProgramNot ApplicableCurrentlyIn past 30 days8. SUD Intensive Outpatient Program (IOP) Level 2.1Not ApplicableCurrentlyIn past 30 days9. SUD Partial Hospitalization Program (PHP) Level 2.2Not ApplicableCurrentlyIn past 30 days10. Residential Crisis Not ApplicableCurrently In past 30 days11. If currently in treatment in one of the services listed above, a written transition plan will be attached to this requestPrimary Medical DiagnosesSocial Elements Impacting DiagnosisNoneEducationalFinancialAccess to Health CareLegal System/CrimePrimary SupportHousing ProblemsOccupationalOther Psychosocial/Enviro.Social EnvironmentHomelessnessUnknownFunctional CriteriaPer medical necessity criteria, at least three of the following must have been present on a continuing or intermittent basis over the past two years.ExampleTo 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. If your answer is “YES” to the questions below, please answer the functional criteria questions: Marked inability to establish or maintain competitive employment.YesNoDescribe 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 functionMarked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management). YesNoDescribe 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 functionMarked inability to establish/maintain a personal support system. YesNoDescribe 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 functionDeficiencies of concentration/ persistence/pace leading to failure to complete tasks. YesNoDescribe 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)YesNoDescribe 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.YesNoDescribe 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.YesNoDescribe 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)Marked functional impairment has been present for less than 2 years.YesNoHas demonstrated marked impaired functioning primarily due to a mental illness in at least three of the areas listed above at least 2 years.YesNoCurrent 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 HistoryYesNoReason for ReferralREASON FOR REFERRAL(Indicate the areas you want the PRP to address.)1) Self-care skillspersonal hygienegroomingnutritiondietary planningfood preparationself-administration of medication2) Social Skillscommunity integration activitiesdeveloping natural supportsdeveloping linkages with and supporting the individual’s participation in community activities3) Independent living skillsskills necessary for housing stabilitycommunity awarenessmobility and transportation skillsmoney managementaccessing available entitlements and resourcessupporting the individual to obtain and retain employmenthealth promotion and trainingindividual wellness self management and recoveryMedical PractitionerMental Health PractitionerMental Health Practitioner NameDateMental Health Practitioner SignatureReset SignaturePlease sign using the mouse or your touchscreenUpload a copy of the current Treatment Plan.PRP Staff: Date Referral, Assertion of Need & Tx Plan ReceivedScreening Scheduled within 5 days? 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