Adult PRP Referral Form

Please fill out all applicable fields on the form. There are some form items that are required. You will not be allowed to complete the form if the required items are not filled in.

Fill out the form items then click “Next”. You will be advanced to the next page. Complete each page and click “Submit” once all pages are completed

Step 1 of 13

Type of Referral

Initial:

Concurrent:

Referral Source Information

Name of person / agency making referral

Date of Referral:

Month

Day

Year

Address

City/ State/ Zip Code

Mental Health Treatment Being Provided

Outpatient Mental Health Services

Inpatient Mental Health Services

Residential Treatment Center

Consumer Information

Name

Date

Month

Day

Year

Age

Address

Social Security #

Sex

Male

Female

Other

City, State, Zip:

Medical Assistance #:

Phone

Access to Transportation for On Site Activities

Yes

Consumer Information Con't

Culture/Ethnicity

Black/African American

White/Caucasian

American Indian/Alaskan Native

Asian

Native Hawaiian/Pacific Islander

Hispanic/Latina

Other

School/Employer Name

Phone

Grade

REFERRAL SOURCE

Referring Agency Name:

Phone

Referring/Treating Clinician (include license & NPI #):

Fax

Address (include city, state, and zip):

This form must be filled out in its entirety to allow for medical necessity and authorization for services. Please do not add diagnoses to the form.

Must meet either criteria 1 or 2 under “Additional Service Criteria Requirements” listed below.

Diagnosis

Category A Diagnosis

F20.81 Schizophreniform Disorder

F20.9 Schizophrenia

F22 Delusional Disorder

F25.0 Schizoaffective Disorder, Bipolar Type

F25.1 Schizoaffective Disorder, Depressive Type

F28 Other Specified Schizophrenia Spectrum and other Psychotic Disorder

F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

F31.2 Bipolar I Disorder, Current or MRE Manic, /w Psychotic Ft

F31.5 Bipolar I disorder, Current or MRE Depressed, /w Psychotic Ft

F33.3 MDD, Recurrent Episode, /w Psychotic Features

Must meet criteria #2 under “Additional Service Criteria Requirements” listed below.

Category B Diagnosis

F31 Bipolar I Disorder, Current or MRE Hypomanic

F31.13 Bipolar I Disorder, Current or MRE Manic, Severe

F31.4 Bipolar I Disorder, Current or MRE Depressed, Severe

F31.81 Bipolar II Disorder, Unspecified

F31.9 Bipolar Disorder, Current or MRE Unspecified

F33.2 Major Depressive Disorder, Recurrent Episode, Severe

F60.3 Borderline Personality Disorder

F31.9 Bipolar Disorder, Current or MRE Unspecified

Current or MRE Hypomanic, Unspecified

Unspecified Bipolar and Related Disorder

Additional Service Criteria Requirements

The individual is enrolled in SSI or SSDI

The referred individual demonstrates impaired functioning for at least two years as evidenced by at least 3 of the following criteria on a continuing or intermittent basis. Please include specifics

Individual doesn’t have two years of impaired functioning as required for a category B diagnosis, but they have a new onset category A diagnosis and PRP services are the most effective means to diminish risk.

Marked inability to establish or maintain independent competitive employment.

Marked inability to perform instrumental activities of daily living (Shopping, meal prep, household chores, med management, transportation, money management)

Marked inability to establish or maintain personal support system.

Marked or frequent deficiencies of concentration, persistence, or pace

Marked inability to perform or maintain self-care (hygiene, grooming, nutrition, medical care, personal safety)

Marked deficiencies in self-direction.

Marked inability to procure financial assistance to support community living.

REHABILITATION SERVICES NEEDED:

Activities of Daily Living

Anger/Temper/Conflict Resolution

Assertiveness/Self-esteem

Community Activity

Family/Natural Supports

Finances

Home/Housing

Self-Care Skills

Self-Injurious Behaviors

Safety to Self/Others

School Performance

Sexual Issues

Social Skills/Peer Interaction

Substance Abuse Issues

Coping Skills

Conflict Resolution

Trauma

Medication Compliance Skills

Vocational Skills

Leisure Skills

Work/Job Performance

Legal Issues

Money Management

Dietary/Food Preparation

Crisis Management Skills

Physical Health

Social Elements Impacting Diagnosis

None

Educational

Financial

Access to Health Care

Legal System/Crime

Primary Support

Housing Problems

Occupational

Other Psychosocial/Environment

Social Environment

Homelessness

Unknown

This individual has a serious mental illness which has required the intervention of the Public Mental Health System in the last two years:

Yes

Individual experiences at least three of the following:

Inability to maintain independent employment.

Social behavior that results in interventions by the mental health system

Inability to procure financial assistance due to cognitive disorganization.

Severe inability to establish or maintain social support.

Need or assistance with basic living skills.

CURRENT TREATMENT(S) GOALS – (please include current treatment goals and type of services received):

Goals:

Please list current DMS-V Diagnosis Code: (If Applicable)

Additional Behavioral Diagnosis:

Diagnosis Code 2:

Description:

Diagnosis Code 3:

Description:

PRIMARY MEDICAL DIAGNOSIS

Diagnosis Code:

Description:

Diagnosed/Referred By: (Please include licensure)

FUNCTIONAL CRITERIA (MANDATORY OPTUM REQUIREMENT – PLEASE FILL OUT)

IF THE CLIENT IS IN SCHOOL, ARE THEY INVOLVED IN ANY AFTER-SCHOOL ACTIVITIES, INCLUDING WORK, WHICH WOULD INTERFERE WITH DELIVERY OF PRP SERVICES?

YES

NOT OF SCHOOL AGE – ADULT CLIENT

IS THE CLIENT CURRENTLY IN MENTAL HEALTH OUTPATIENT TREATMENT?

Yes

AT LEAST 1X/WEEK

AT LEAST 1X/MONTH

AT LEAST 1X/6 MONTHS

HOW LONG HAS THE INDIVIDUAL BEEN ENGAGED IN ACTIVE OUTPATIENT TREATMENT?

LESS THAN ONE MONTH

2-3 MONTHS

4-6 MONTHS

7-12 MONTHS

MORE THAN 12 MONTHS

IS THERE EVIDENCE OF SIGNIFICANT PSYCHOLOGICAL OR SOCIAL IMPAIRMENTS CAUSING SERIOUS PROBLEMS WITH PEER RELATIONSHIPS AND/OR FAMILY MEMBERS?

Yes

in what areas...

Paranoia

Hallucinations / Delusions

Frequent mood swings / elevated mood

Aggressive behaviors

Poor concentration – unable to follow directions

Sadness/hopelessness

Frequent irritability

Risk taking behaviors / self-harm

Unwanted thoughts/delusions

Isolated and/or withdrawn

THE IMPAIRMENT AS A RESULT OF THE CLIENT’S MENTAL ILLNESS RESULTS IN:

CLEAR, CURRENT THREAT TO THE INDIVIDUAL’S ABILITY TO BE MAINTAINED IN HIS OR HER CUSTOMARY SETTING, AND/OR

AN EMERGING/PENDING RISK TO THE SAFETY OF THE INDIVIDUAL OR OTHERS.

WILL THE CLIENT’S LEVEL OF COGNITIVE IMPAIRMENT, CURRENT MENTAL STATUS, OR DEVELOPMENTAL LEVEL IMPACT THEIR ABILITY TO BENEFIT FROM PRP?

Yes

IS THE CLIENT TRANSITIONING FROM AN INPATIENT, DAY HOSPITAL, OR RESIDENTIAL TREATMENT SETTING TO A COMMUNITY SETTING?

Yes

HAS MEDICATION BEEN CONSIDERED FOR THIS CLIENT (PLEASE SELECT ONE)?

Yes

ADULTS ONLY

HAS THE CLIENT DEMONSTRATED MARKED FUNCTIONAL IMPAIRMENT FOR AT LEAST 2 YEARS?

Yes

IS THE CLIENT CURRENTLY EMPLOYED?

Yes

IS THERE EVIDENCE OF THE CLIENT’S INABILITY TO ESTABLISH OR MAINTIAN COMPETITIVE EMPLIYMENT? (Select all that apply)

Yes

Pervasive pattern of unemployment / underemployment

Sporadic employment / unable to sustain employment due to mental health symptoms such as:

IS THERE EVIDENCE OF THE CLIENT’S INABILITY TO ESTABLISH OR MAINTIAN COMPETITIVE EMPLIYMENT? (Select all that apply)

Poor Time Management

Poor Decision Making

Ineffective Communication

Poor Emotional Skills

IS THERE EVIDENCE OF MARKED INABILITY TO PERFORM INSTRUMENTAL ACTIVITIES OF DAILY LIVING?

Yes

in what areas ...

Shopping

Meal Preparation

Laundry

Housekeeping / Cleanliness

Medication Management

Transportation

Financial / Money Management

Ineffective Communication

Poor Emotional Skills

IS THERE EVIDENCE OF MARKED INABILITY TO MAINTAIN OR SUSTAIN PERSONAL SUPPORT SYSTEM?

Yes

in what areas ...

Lack of Family Support

Poor Family Relationships

Poor / unstable friendships

Lack of Community Involvement

Poor Social Skills

Intolerable Social Behaviors

Withdrawn

Isolation

Trust Issues / Suspicious of Others

Interpersonal Conflict

IS THERE EVIDENCE OF MARKED DEFICIENCES IN CONCENTRATION, PERSISTENCE, OR PACE?

Yes

in what areas ...

Failure to Complete Tasks Timely

Failure to/or Inability to Recall Important Information

Losing Track of Important Independent Living Items such as pay bills and time management.

IS THERE EVIDENCE OF MARKED DEFICIENCES IN MAINTAINING SELF CARE?

Yes

in what areas ...

Poor Hygiene

Poor Grooming

Poor Nutrition

Poor / Lack of Medical Care

Poor Personal Safety Skills

IS THERE EVIDENCE OF MARKED DEFICIENCES IN SELF MANAGEMENT/DIRECTION?

Yes

in what areas ...

Poor Independent Planning

Poor Ability to Initiate Important Life Tasks

Poor Organizational Skills

IS THERE EVIDENCE OF MARKED DEFICIENCES IN PROCURING FINANCIAL ASSISTANCE TO SUPPORT COMMUNITY LIVING?

Yes

DOES THE PARTICIPANT HAVE IMPAIRMENTS RELATED TO THE PRIORITY POPULATION DIAGNOSIS IN 3 OR MORE OF THE FUNCTIONAL AREAS LISTED?

Paranoia

Hallucinations / Delusions

Frequent mood swings / elevated mood

Aggressive behaviors

Poor concentration – unable to follow directions

Sadness / hopelessness

Frequent irritability

Risk taking behaviors / self-harm

Unwanted thoughts/delusions

Isolated and/or withdrawn

PLEASE PROVIDE AN EXAMPLE OF THE SELECTIONS MADE ABOVE:

MEDICATIONS (IF ANY, PLEASE FILL OUT BELOW:

1. Type of Medication

1. Dosage

1. Frequency

2. Type of Medication

2. Dosage

2. Frequency

3. Type of Medication

3. Dosage

3. Frequency

Custodial Care (MINORS ONLY):

Name of Guardian:

Phone

Address:

Foster Care Placement/DSS (if applicable):

Consent

I agree to the COLLABORATION AGREEMENT

I, agree to participate in team treatment planning sessions/initial session within two weeks of receipt of the referral and quarterly sessions in person or by phone.
** Please submit this form to our office along with relevant medical records (Clinic/hospital notes, test, lab or other imaging results, and pertinent consultations. Please include any necessary insurance referral authorizations. Thank you.)

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Referring Provider/Agency Staff

Position/Title:

Date

Month

Day

Year

Signature

Clinical Director/Co-Signer

Position/Title:

Date

Month

Day

Year

Signature

Choose the service that you would like to make a referral for:

Adult PRP

Minor PRP