Child PRP Form

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Referral for Psychiatric Rehabilitation Program (Child-PRP)

Referral Source Information

Date of Referral:

Referral Source Information

Initial Referral

Concurrent Referral

Name and credentials of person / agency making referral:

Supervisor and Credentials (If applicable)

Agency

Phone Number of Referrer

Referral Email *

Address

Apt, suite, etc.

Country

City

State

Zip code

Mental Health Treatment Being Provided

Outpatient Mental Health Services

Inpatient Mental Health Services

Residential Treatment Center

Participant Information

Name

Medicaid #

Date of Birth

Age

Gender Identification

Male

Female

Transgender Male/Trans Man/(F to M)

Transgender Female/Trans Woman/(M to F)

Genderqueer (or gender nonconforming)

Decline

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone Number

Sexual Orientation

Heterosexual

Gay/Lesbian

Bisexual

Don’t Know

Decline

Something Else, Please Describe:

Language Preference:

Race/Ethnicity:

Amer. Indian/Alaskan Native

Asian

White

Black/African American

Native American / Hawaiian or Other Pacific Islander

Hispanic

Non-Hispanic

Additional Gender Category, please specify:

Access to Transportation for On Site Activities

Yes

School Name

Grade

Truancy/ Educational Concerns

Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

DSS involvement

Qualifying Diagnosis

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

CATEGORY A

F20.0 Paranoid Schizophrenia

F20.1 Disorganized Schizophrenia

F20.2 Catatonic Schizophrenia

F20.3 Undifferentiated Schizophrenia

F20.5 Residual Schizophrenia

F20.81 Schizophreniform Disorder

F20.89 Other Schizophrenia

F20.9 Schizophrenia, unspecified

F25.0 Schizoaffective, bipolar

F25.1 Schizoaffective, depressive

F25.8 Other Schizoaffective

F25.9 Schizoaffective, unspecified

F22 Delusional disorder

F28 Other psychotic disorder

F29 Unspecified psychosis

F31.2 Bipolar I, manic severe w/psych ft

F31.5 Bipolar I d/o depress sev w/psych ft

F31.64 Bipolar I d/o mix sev w/psych ft

F33.3 MMD, recurrent sev w/psych ft

Other

CATEGORY B

F31.0 Bipolar I, Most Recent Hypomanic

F31.13 Bipolar I, Most Recent Manic, Severe

F31.4 Bipolar I, Most Recent Depressed, Severe

F31.63 Bipolar d/o, mix severe w/o psych

F31.81 Bipolar II Disorder

F31.9 Bipolar disorder, unspecified

F33.2 MDD, Recurrent Episode, Severe

F60.3 Borderline Personality Disorder

(If box is checked, answer questions below)

Duration of current episode of treatment provided to this participant

Less than one month

1-3 months

4-6 months

7-12 months

More than 12 months

3. Current frequency of treatment provided to this individual:

At least 1x/week

At least 1x/2 weeks

At least 1x/month

At least 1x/3 months

At least 1x/6 months

Receiving SSI or SSDI

Yes, Please upload a copy with referral

Unknown

Upload Current Treatment Plan

Functional Criteria

FUNCTIONAL CRITERIA

Per medical necessity criteria, at least three of the following must have been present on a continuing or intermittent basis over the past two years.

If the impairments have been for at least 2 years, check at least 3 criteria below, if apply:

Marked inability to establish or maintain competitive employment.

Marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management).

Marked inability to establish/maintain a personal support system

Marked or frequency deficiencies of concentration, persistence, pace

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

Marked deficiencies in self-direction

Marked inability to procure financial assistance to support community living.

Duration of Impairment(s)

Social Elements Impacting Diagnosis

None

Educational

Financial

Access to Health Care

Legal System/Crime

Primary Support

Housing Problems

Occupational

Other Psychosocial/Enviro.

Social Environment

Homelessness

Unknown

Clinical Assessment

(Please add a brief summary of the Functional criteria Selected Above, including symptoms and functional impairments )

Mental Health Practitioner

Mental Health Practitioner Name

Date

Mental Health Practitioner Signature

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Clinical Supervisor Name

Clinical Supervisor Signature

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Child PRP Form

Referral for Psychiatric Rehabilitation Program (Child-PRP)

Referral Source Information

Participant Information

Participant Information

Parent/Guardian Information

Qualifying Diagnosis

Functional Criteria

FUNCTIONAL CRITERIA

Duration of Impairment(s)

Accreditation

Address

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