Therapist Referral

CLIENT DEMOGRAPHICS

Client's Name

Date of Birth

Age

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home Phone

Social Security Number

Medical Assistance

Sex

Ethnicity

Religion

Marital Status

REFFERAL SOURCE

The 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 *

Agency

Contact Person

Primary Clinical Provider

Email Address

Phone

Ext:

Fax:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

DSM-V DIAGNOSIS

Behavioral

Diagnostic Category

Code

Description

Diagnostic Category

Code

Description

Diagnostic Category

Code

Description

DSM-V DIAGNOSIS

Medical

Diagnostic Category

Code

Description

Diagnostic Category

Code

Description

Diagnostic Category

Code

Description

DSM-V DIAGNOSIS

Social Elements Impacting Diagnosis (Check all that Apply)

Diagnosing Clinician

Diagnosing Clinician Title

1. Is the individual eligible for full funding for Developmental Disabilities Administration services?

YesNo

2. Have family or peer supports been successful in supporting this youth?

YesNo

3. Is the primary reason for the youth’s impairment due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?

YesNo

4. Does the youth meet criteria for a higher level of care than PRP?

YesNo

5. Will the youth’s level of cognitive impairment, current mental status or developmental level impact their ability to benefit for PRP?

YesNo

PRESENTING COMPLAINT:

Please check the following rehabilitation and support services that the client may need:

Independent 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 treatment

HISTORY 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?

YesNo

Current frequency of treatment provided to this individual:

☒ At least 1x week☐ At least 1x/2 weeks☐ At least 1x/month☐ At least 1x/6months

In 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 months

Is 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?

YesNo

Additional 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?

YesNo

5. Has an individual treatment plan/rehabilitation plan been completed?

YesNo

a. Is the participant/guardian involved in the preparation of the plan?

YesNo

b. 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/Title

Date

HANDS ACROSS BALTIMORE

Intake Form