Psychiatric Rehabilitation Program - Linthicum, MD



Psychiatric Rehabilitation ProgramInitial Referral FORMToday’s Date: FORMTEXT ?????Type of Referral: FORMCHECKBOX On Site FORMCHECKBOX Off Site Sex: FORMCHECKBOX Bothreferral source INFORMATIONName: FORMTEXT ????? Title: FORMTEXT ?????Email: FORMTEXT ?????Agency: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Participant INFORMATIONLast Name: FORMTEXT ?????First Name: FORMTEXT ?????Middle: FORMTEXT ?????Date of Birth: FORMTEXT ?????Age: FORMTEXT ?????Sex: FORMCHECKBOX F FORMCHECKBOX MSocial Security No: Home Phone: FORMTEXT ?????Cell Phone: FORMTEXT ?????Address: FORMTEXT ?????Emergency Contact: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Does participant have a guardian of person or property? FORMCHECKBOX Yes FORMCHECKBOX No If so, who? FORMTEXT ?????Phone: FORMTEXT ?????Marital Status: FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Separated FORMCHECKBOX Never Married FORMCHECKBOX WidowedEmployed? FORMCHECKBOX Yes FORMCHECKBOX NoIf So: FORMCHECKBOX Full-Time FORMCHECKBOX Part-TimeDescribe the Participant’s Support System: FORMTEXT ?????INSURANCE/Financial INFORMATIONMedical Assistance No.: FORMTEXT ?????If the Participant does not have Medical Assistance, what was the date of application? FORMTEXT ?????Medicare No.: FORMTEXT ?????Other Insurance: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, name of carrier: FORMTEXT ?????Reason for referralCheck all that apply*: FORMCHECKBOX Emotional/Mental Illness - Social behavior resulting in interventions by the mental health system FORMCHECKBOX Legal System/Crime/Incarceration Issues FORMCHECKBOX Employment/ Occupational - Inability to maintain independent employment FORMCHECKBOX Medication Compliance/Monitoring FORMCHECKBOX Financial Difficulty - Inability to procure financial assistance due to cognitive issues FORMCHECKBOX Physical/Emotional Abuse FORMCHECKBOX Behavior Conduct/Crisis Intervention - dangerous behavior issues FORMCHECKBOX Sexual Abuse FORMCHECKBOX Social Environment/Interpersonal Skill issues - Severe inability to establish or maintain social supports FORMCHECKBOX Relationship Issue/Conflict FORMCHECKBOX Educational/School Problems FORMCHECKBOX Primary/Family Support FORMCHECKBOX Housing Problems/Homelessness/At Risk of Homelessness FORMCHECKBOX Substance Abuse (participant or family) FORMCHECKBOX Anger Management/Conflict Resolution FORMCHECKBOX Suicidal/Homicidal Risk FORMCHECKBOX Activities of Daily Living - Need or assistance with basic living skills FORMCHECKBOX CPS/APS/DSS Involved FORMCHECKBOX Access to Health Care FORMCHECKBOX Independent-living Skill Training FORMCHECKBOX Other Psychosocial/Environment - including adaptive resources FORMCHECKBOX Personal Hygiene/Grooming*At least three are required to meet the medical necessity criteria.PRP Services REquestedCheck all that apply:Self-Care Skills FORMCHECKBOX Personal Hygiene FORMCHECKBOX Grooming FORMCHECKBOX Nutrition FORMCHECKBOX Dietary Planning FORMCHECKBOX Food Preparation FORMCHECKBOX Self-Administration of Medication.Social Skills FORMCHECKBOX Community Integration Activities FORMCHECKBOX Developing Natural Supports FORMCHECKBOX Supporting the Individual’s Participation in Community Activities FORMCHECKBOX Social Relationships & Leisure Activities FORMCHECKBOX Recovery ChallengesIndependent Living Skills FORMCHECKBOX Skills necessary for Housing Stability FORMCHECKBOX Community Awareness FORMCHECKBOX Mobility and Transportation Skills FORMCHECKBOX Money Management FORMCHECKBOX Accessing available Entitlements and Resources FORMCHECKBOX Supporting the Individual to obtain and retain Employment FORMCHECKBOX Health Promotion and Training Individual Wellness FORMCHECKBOX Self -Management and Recovery FORMCHECKBOX Education and Vocational TrainingPresenting Complaints, symptoms and behaviorsCheck all that apply: FORMCHECKBOX Anxiety/Panic FORMCHECKBOX Depression FORMCHECKBOX Suicidal/Homicidal Ideation FORMCHECKBOX Stealing FORMCHECKBOX Hyperactive FORMCHECKBOX Property Destruction FORMCHECKBOX Irritable FORMCHECKBOX Isolative FORMCHECKBOX Manipulative/Lying FORMCHECKBOX Manic Mood FORMCHECKBOX Obsession/Compulsion FORMCHECKBOX Oppositional Defiant FORMCHECKBOX Physical Aggression FORMCHECKBOX Impulsive FORMCHECKBOX Hopelessness/ Helplessness FORMCHECKBOX Self-Care Deficit FORMCHECKBOX Self-Injurious Behavior FORMCHECKBOX Harm to Others FORMCHECKBOX Separation Problems FORMCHECKBOX Wandering FORMCHECKBOX Sexually Inappropriate FORMCHECKBOX Trauma-Related FORMCHECKBOX Verbal Aggression FORMCHECKBOX Other Psychosocial IssuesFax to (443) 400-8392Clinical INFORMATIONAuthorizations Require a DSM 5 Diagnosis. Please check all that apply: FORMCHECKBOX F20.9 Schizophrenia FORMCHECKBOX F31.2 Bipolar I, Most Recent Manic, with Psychosis FORMCHECKBOX F20.81 Schizophreniform Disorder FORMCHECKBOX F31.4 Bipolar I, Most Recent Depressed, Severe FORMCHECKBOX F25.0 Schizoaffective Disorder, Bipolar Type FORMCHECKBOX F31.5 Bipolar I, Most Recent Depressed, with Psychosis FORMCHECKBOX F25.1 Schizoaffective Disorder, Depressive FORMCHECKBOX F31.0 Bipolar I, Most Recent Hypomanic FORMCHECKBOX F28 Other Specified Schizophrenia Spectrum/Other Psychotic Disorder FORMCHECKBOX F31.9 Bipolar I, Most Recent Hypomanic, Unspecified FORMCHECKBOX F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder FORMCHECKBOX F31.9 Bipolar I Disorder, Unspecified FORMCHECKBOX F22 Delusional Disorder FORMCHECKBOX F31.9 Unspecified Bipolar Disorder FORMCHECKBOX F33.2 Major Depressive DO, Recurrent Episode, Severe FORMCHECKBOX F31.81 Bipolar II Disorder FORMCHECKBOX F33.3 Major Depressive DO, Recurrent, With Psychotic Features FORMCHECKBOX F21 Schizotypal Personality Disorder FORMCHECKBOX F31.13 Bipolar I, Most Recent Manic, Severe FORMCHECKBOX F60.3 Borderline Personality DisorderPlease list any allergies: FORMTEXT ?????Please list current medications and dosage: FORMTEXT ?????Medication compliance history: FORMTEXT ?????Total number of past hospitalizations: FORMTEXT ?????Date and Location of most recent hospitalization: FORMTEXT ?????Reason for admission: FORMTEXT ?????Substance Abuse InformationHistory of Substance Abuse? Has the Participant received inpatient or outpatient substance abuse treatment? FORMCHECKBOX Yes FORMCHECKBOX No If yes, date and location: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No Please describe substance abuse history: FORMTEXT ?????Medical DiagnosesPlease list any current medical diagnoses: FORMTEXT ????? FORMTEXT ?????Treatment providersPrimary Care Physician (PCP): FORMTEXT ?????Address: FORMTEXT ?????Phone No.:Fax No.:Email:Organization: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Psychiatrist: FORMTEXT ?????Address: FORMTEXT ?????Phone No.:Fax No.:Email:Organization: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Mental Health Therapist: FORMTEXT ?????Address: FORMTEXT ?????Phone No.:Fax No.:Email:Organization: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ?????Address: FORMTEXT ?????Phone No.:Fax No.:Email:Organization: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Signature of Referral SourceReferral Source Signature and CredentialsDateFoundations PRP1025 W Nursery Road, Suite 118Linthicum, MD 21090Phone: (443) 422-6939 Fax: (443) 400-8392 ................
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