Life Renewal ServicesBehavioral Health Center

Minor / Adult

Date: ____/____/_____PRP Referral Form

Demographics

Last Name: / First Name: / DOB: / Sex: F M
Race:
Address:
City: / State: / Zip: / Email Address:
Phone(1): / MA#: / SSN:
School Attending: / Current/ Highest Grade Completed:
Marital Status: / Resides with:
Parent/ Guardian: / Relationship: / Do the Parent/ Guardian have legal custody of the minor? YES/ NO
If parent does not have custody, please provide custodial information:
Name: / Phone #:
Address:
City: / State: / Zip:

**Please Note: Services cannot begin unless proof of custody is provided**

Does the client have an IEP? YES / NO / If Yes, level of Special Education:
PCP & Location: / Phone #:

Financial

Employment Status: / MA#:
Payment Source: / Income Source:

Referral Information:

Referring Clinician Signature: ______ / Date: ______
Referring Clinician/ Credentials (Printed):______

Phone Number: ______Email Address: ______

Reason for Referral (Client Needs and Presenting Problem):

Client Strengths:

Substance Abuse?: YES/ NO / If yes, type:
Legal Involvement?: YES/ NO / If yes, type:
Previous/ Current Suicidal Ideation: YES / NO;
If yes, please explain:
Past Psychiatric Admission(s): YES / NO / Previous Outpatient Treatment: YES / NO
Current Outpatient Provider: / Phone:
Primary Behavioral Dx: / Primary Medical Dx:

Please check off the following rehabilitation and support services that the MINOR may need:

Age Appropriate self care skills, including:
Personal Hygiene / Nutrition
Grooming / Dietary Planning
Food Preparation
Self administration of medication
Social Skills - developing natural supports and developing linkages with supporting minor's participating in community activities
Conflict Resolution
Anger Management
Maintaining Personal Living Space
Maintaining Age-appropriate boundaries
Activities that support consumer's cultural interests
Maintaining personal safety in social environment
Time management including use of structured and unstructured time
Independent Living Skills including:
Mobility skills / Maintenance of the consumer's living environment
Money Management / Community awareness
Interactive skills with peers and authority figures
Promotion of Illness Self-Management
Providing education and information regarding mental illness
Identifying effecting strategies to assist the consumer to manage the consumer's illness
Potential problematic symptoms
Warning signs of relapse, helpful interventions and utilizing other individuals to resolve the situation in order for the consumer to remain in service or to seek treatment.
Accessing available entitlements and resources

Please check off the following rehabilitation and support services that the ADULT may need:

Age Appropriate self care skills, including:
Personal Hygiene / Nutrition
Grooming / Dietary Planning
Food Preparation
Self administration of medication
Social Skills - developing natural supports and developing linkages with supporting consumer's participating in community activities
Activities that support consumer's cultural interests
Independent Living Skills including:
Mobility and transportation skills / Maintenance of the consumer's living environment
Money Management / Community awareness
Promotion of Illness Self-Management
Providing education and information regarding mental illness
Identifying effecting strategies to assist the consumer to manage the consumer's illness
Potential problematic symptoms
Warning signs of relapse, helpful interventions and utilizing other individuals to resolve the situation in order for the consumer to remain in service or to seek treatment.
Accessing available entitlements and resources
Supporting the individual to obtain and retain employment
Skills necessary for housing stability

Please explain how the Psychiatric Rehabilitation Program (PRP) can provide assistance with the above marked services and how PRP can help the consumer manage their disorder and to support recovery as it relates to their treatment goals:

Case Management Needs:

***Please forward copies of custody papers (if legal guardian is not the biological parent). Please attach copy of initial clinical evaluation and latest clinical treatment plan.***

Please Fax this Form to:

(443) 821-3280 (Carroll County)