HANDS ACROSS BALTIMORE Therapist Referral Contact Info HANDS ACROSS BALTIMORE, LLCAddress: 2423 Maryland Avenue Suite 202 Baltimore, MD. 21218-5083 Email: firstname.lastname@example.org Phone: (443) 682-8820 Intake Form CLIENT DEMOGRAPHICSClient's NameDate of BirthAgeStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeHome PhoneSocial Security NumberMedical AssistanceSexSexMaleFemaleEthnicityReligionMarital StatusMarital StatusSingleMarriedDivorcedREFFERAL SOURCEThe referring clinician must be a Licensed Mental Health Professionals. Which includes Psychiatrists, CRNP-PMH, Licensed Psychologists, LCSW-C, LCPC, APRN-PMH, LCMFT, LCADC, LCPAT, LGMFT, LGADC, and LGPAT. If they have their LGPC, LGMFT, LGADC, LGPAT, LMSW.Clinical supervisor's credentials * AgencyContact PersonPrimary Clinical ProviderEmail AddressPhoneExt:Fax:Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDSM-V DIAGNOSISBehavioralDiagnostic CategoryCodeDescriptionDiagnostic CategoryCodeDescriptionDiagnostic CategoryCodeDescriptionDSM-V DIAGNOSISMedicalDiagnostic CategoryCodeDescriptionDiagnostic CategoryCodeDescriptionDiagnostic CategoryCodeDescriptionDSM-V DIAGNOSISSocial Elements Impacting Diagnosis (Check all that Apply)Social Elements Impacting DiagnosisNoneProblems with access to healthcare servicesHousing problems (not homelessness)Problems related to the social environmentEducation problemsProblems related to interactions with legal system/crimeOccupational problemsHomelessnessFinancial problemsProblems with primary support groupsOther psychological and environmental problems(Check all that Apply)Diagnosing ClinicianDiagnosing Clinician Title1. Is the individual eligible for full funding for Developmental Disabilities Administration services?YesNo2. Have family or peer supports been successful in supporting this youth?YesNo3. Is the primary reason for the youth’s impairment due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?YesNo4. Does the youth meet criteria for a higher level of care than PRP?YesNo5. Will the youth’s level of cognitive impairment, current mental status or developmental level impact their ability to benefit for PRP?YesNoPRESENTING COMPLAINT:Please check the following rehabilitation and support services that the client may need:Age-Appropriate self-care skills, including:Personal hygieneNutritionGroomingDietary planningFood preparationSelf-administration of medicationParticipation in community activitiesTime management including use of structured and unstructured timeAnger managementConflict resolutionMaintaining personal living spaceMaintaining age-appropriate boundariesActivities that support minor’s cultural interestMaintaining personal safety in social environmentSocial Skills – developing natural supports, and developing linkages with supporting minorsIndependent Living Skills including:Maintenance of the minor’s living environmentMobility skillsCommunity awareness skills with peers and authority figuresMoney management InteractivePromotion of Illness Self-ManagementProviding education and information regarding mental illnessIdentifying effective strategies to assist the minor to manage the minor’s potential problematic symptoms ☐The situation in order for the minor to remain in service or to seek treatmentThe situation in order for the minor to remain in service or to seek treatmentHISTORY OF PRESENTING PROBLEM(S):Please explain how psychiatric rehabilitation providing the above services can help client manage their disorder and to support recovery as it relates to their treatment goals:Consumer will benefit from PRP services to help:Has the client been arrested in the last 30 days?YesNoCurrent frequency of treatment provided to this individual:☒ At least 1x week☐ At least 1x/2 weeks☐ At least 1x/month☐ At least 1x/6monthsHow long has youth been engaged in active, documented outpatient treatment?Less than one month2-3 months4-6 months7-12 months☒ More than 12 monthsIn the past three months, how many ER visits has the youth had for psychiatric care?No visits in the last three monthsOne visit in the last three monthsTwo or more visits in the last three monthsIs the youth transitioning from inpatient day hospital or residential treatment setting to a community setting?YesNoIf Yes: What level of care is the youth transitioning from and to? (Describe below)If Yes: What level of care is the youth transitioning from and to?Does the youth have a Targeted Case Management referral or authorization?YesNoHas medication been considered for this youth?Not consideredConsidered and Ruled OutInitiated and WithdrawnOngoingOtherAdditional Information:FUNCTIONAL IMPAIRMENT (S):1. Within the past three months, the individual’s emotional disturbances have resulted in: a) A clear current threat to the youth's ability to be maintained in their customary setting.YesNoEvidence of a clear current threat to the youth's ability to be maintained in their customary setting.b) An emerging risk to the safety of the youth or others?YesNoEvidence of an emerging risk to the safety of the youth or others.c) Significant psychological or social impairments causing serious problems with peer relationships and/or family members? ☒YES ☐NO Evidence of significant psychological or social impairments causing serious problems with peer relationships and/or family members?YesNoEvidence of significant psychological or social impairments causing serious problems with peer relationships and/or family members.2. What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth's symptoms and functional behavioral impairments resulting from mental illness?3. How will PRP serve to help this youth get to age appropriate development, more independent functioning and independent living skills?4. Has a crisis plan been completed with family and/or guardian?YesNo5. Has an individual treatment plan/rehabilitation plan been completed?YesNoa. Is the participant/guardian involved in the preparation of the plan?YesNob. Is the participant/guardian involved in agreement with the plan?YesNoIf no, provide explanation of extenuating circumstances below.For Reauthorizations:Has the youth made progress toward age-appropriate development, more independent functioning and independent living skills?YesNoIf Yes: Describe the improvement below. If No: Indicate changes in treatment plan to address lack of progress below.Primary Clinical Provider/TitleDateSubmit!