PRP Referral PRP Referral FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Patient Name *FirstLastLayoutDate of Birth *Sex:Race:Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number *Emergency Contact: (Relationship to Patient)Highest Grade Completed:Contact's Phone *Current Patient Status (please indicate to assist in the prioritization of referrals): Inpatient- projected release date:Parcial Hospitalization- projected release date:Crises Bed/Other crisis facility- projected release date:OutpatientDate of most recent inpatient discharge:Other:Support for Patient?YesNoReferral Source Agency *Therapist *Address *Phone number *FaxEmail *DSM 5 Behavioral Diagnoses: DSM-5 / ICD-10 Behavioral Diagnosis: (Patient must have one of these diagnoses as primary)295.90/F20.9 Schizophrenia295.40/F20.81 Schizophreniform Disorder295.70/F25.0 Schizoaffective Disorder, Bipolar Type295.70/F25.1 Schizoaffective Disorder,Depressive Type298.8/F28 Other Specified Schizophrenia Spectrum or Other Psychotic Disorder298.9/F29 Unpecified Schizophrenia Spectrum of Other Psychotic Disorder296.33/F33.2 Major Depressive Disorder, Recurrent Episode, Severe296.34/F33.3 Major Depressive Disorder, Recurrent Episode, Severe with Psychotic Features296.43/F31.13 Bipolar I Disorder, Current or most Recent Episode Manic, Severe296.44/F31.12 Bipolar I Disorder, Current or most Recent Episode Manic, Severe, with Psychotic Features296.53/F31.4 Bipolar I Disorder, Current or most Recent Episode, Depressive Severe296.54/F31.5 Bipolar I Disorder, Current or most Recent Episode Depressed, Severe with Psychotic Features296.40/F31.0 Bipolar I Disorder, Current or most Recent Episode Hypomatic296.7/F31.9 Bipolar I Disorder, Unspecified296.89/F31.81 Bipolar II Disorder301.22/F21 Schizotypal Personality Disorder301.83/F60.3 Borderline Personality DisorderNextIn order to qualify for PRP program, patient must meet the target diagnostic criteria and meet the following functional limitations. Serious mental illness is characterized by impaired role functioning, on a continuing or intermittent basis for at least two years including at least three (3) of the following:Social Elements Impacting DiagnosisProblems with access to health care ServiceHousing Problems (Not Homelessness)Problems with primary support groupEducational ProblemsProblems Related to Interaction W/Legal Systems/CrimeHomelessnessProblems related to the Social EnvironmentOccupational ProblemsOther Psychosocial and Environment ProblemsMedical disabilities that impact diagnosis or must be accommodated for in treatmentClient would benefit with assistance in developing the following skills to be successful in their recovery:Activities of Daily LivingAnger/Temper/Conflict ResolutionAssertiveness/Self-esteemCommunity ActivityFamily/Natural SupportsFinances/BudgetingHome/HousingSelf Care SkillsSafety to Self/OthersSchool PerformanceSexual IssuesSocial Interaction SkillsSubstance Abuse IssuesCoping SkillsTraumaMedication Compliance SkillsVocational SkillsLeisure SkillsWork/Job PerformanceLegal IssuesMoney ManagementDietary/Food PreparationCrisis Management SkillsDiagnosis has created difficulty in their ability develop or restore their independent living and social skills. Please note the following functional impairments:Inability to maintain independent employmentSocial behavior that results in interventions by the mental health systemSeverely impaired concentration or thought organizationInability to obtain financial assistance to support living in the communitySevere inability to establish or maintain a personal support systemNeed for assistance with basic living skillsAn inability to manage the effects of his/her mental illnessLess treatment was insufficient in preventing deterioration and requires stabilizationPreviousSubmit
