RESOURCES

Psychiatric Rehabilitation

Program Referral Form

TEAM OF EXPERTS

PERSONALIZED TREATMENT PLANS

CONVENIENT CARE

FILL OUT & SUBMIT OUR SECURE FORM

PRP Referral Form

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

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

Outpatient

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)

Social Elements Impacting Diagnosis: (check all that apply)

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

Entitlement Information:

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:

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.)

(Clinician’s Signature)
(Print Consumer’s Name)
(Print Clinician’s Name and Credentials)
(Clinician’s Phone Number)

FREQUENTLY ASKED QUESTIONS

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