E & S Behavioral Health Sciences | Adolescent PRP Referral

Requested Date of Assessment:

Current Diagnosis:
Please indicate the current ICD-10 Codes:

Reason for Referral:
(Please explain how the client’s diagnosis is a barrier for community integration)

Frequency & Severity of Issue:

Recent Hospitalizations:

Lethality or Safety Issues

Relevant Medical Diagnosis:

Is the individual currently receiving any of the following services:

Mobile treatment servicesAssertive community treatment (act)Adult targeted case management (tcm)Inpatient metal health -residential treatment center (rtc)Residential sud treatment level 3.3 and higher substance use disorderIntensive outpatient/2.1Mental health intensive outpatient / partial hospitalization programResidential crisisNone

Rehabilitation

Services Requested

I am verifying that continues to need services from our Rehabilitation Program. Services needed include assessment and continued on-site and/or off-site psychiatric rehabilitation services and crisis management. This service is medically necessary to facilitate the client’s wellness and recovery and is based on my assessment of need in the following areas: Please check all that apply.

Inability to establish or maintain employment (pattern of unemployment, underemployment, or sporadic work history)Inability to establish or maintain personal relationships (social withdrawal or isolation, interpersonal conflict or social behavior, other than criminal that is not easily tolerated by the community)Deficiencies in self-direction (inability to independently plan, initiate, organize, and carry out goal directed activities)Inability to perform instrumental activities of daily living (shopping, meal preparation laundry, basic housekeeping, medication management, transportation, and money management)Inability to perform or maintain self-care (hygiene, grooming, nutrition, medical are, personal safety)Inability to procure financial assistance to support community living

Is the client currently receiving services with another provider?

Organization Name:

Dates of services:

Referral

Source information

Referral Source Name:

Referral Source Phone #:

Referral Source Credentials

Referral Source Address:

Referral Source Signature:

Referral Source Printed Name:

Masters or Graduate Level Supervisor Name if Applicable

Adolescent PRP Referral

Rehabilitation

Services Requested

Current Medication

Referral

Source information