PRP Referral Form-2 - americanpsychiatricgroup

To efficiently process referrals, please fill out this form in its entirety, sign, and date.

Date

Consumer Name:

SS#:

Date

SEX

RACE

STREET ADDRESS

City:

State:

Zip:

Country:

Phone (Home):

(Work/Mobile):

Physical Description:

Highest Grade Completed:

Emergency Contact (Relationship to Consumer):

Contact’s Phone (Home):

(Work/Mobile):

Support for Client?

yes
No

Current consumer status (please indicate to assist in the prioritization of referrals):

Inpatient- projected release date:

Partial Hospitalization- projected release date:

Crisis Bed/Other crisis facility- projected release date:

Outpatient

Date of most recent inpatient discharge:

Other:

DSM 5 Behavioral Diagnoses:

Code(s)

Priority Pop. DSM-5 / ICD-10 Behavioral Diagnosis: (consumer must have one of these diagnoses as primary to qualify for services)

Additional Behavioral Health Diagnosis:

Primary Medical Diagnosis:

Social Elements Impacting Diagnosis: (check all that apply)

Functional Assessment:

Definition of Problem Areas (Current Symptoms):

Reason(s) for seeking treatment (check all that apply):

Linkage to community resources/community integration
Facilitating transition from more intensive services
Prevention/reduction of hospitalization or rehospitalization
Coordination of current community services

Other:

Risk for Aggressive Behaviors, Suicide, or Homicide: (explain):

Entitlement Information:

SSI monthly: $

Date Active:

SSDI monthly: $

Date Active:

Medicaid #:

Date Applied / Active

Other Income/Insurance:

If consumer does NOT have medical assistance/Medicaid, he or she must meet one or more of the following criteria to qualify for services through Uninsured Eligibility Coverage:

Currently homeless or at risk for homelessness
Has had an inpatient hospitalization within the last three (3) months
Has been incarcerated within the last three (3) months

Upon the clinician’s signature below, the consumer being referred is appropriate for psychiatric rehabilitation program services provided by Partnership Development Group, Inc. This referral must be signed by a physician, nurse practitioner, or independently licensed clinician (LCSW-C or LCPC.)

I,

(Clinician’s Signature)

refer

(Print Consumer’s Name)

(Print Clinician’s Name and Credentials)

(Clinician’s Phone Number)