PRP REFERRAL FORM

Psychiatric Rehabilitation Program

PRP REFERRAL FORM
Name
Gender
- Male
- Female
- Transgender
Address
Phone (Home)
Phone (Cell)
Phone (Work)
D.O.B.
MM slash DD slash YYYY
SSN
Active
- Yes
- No
Race
Marital Status
Employment
Highest level of education
Veteran
- Yes
- No
Number of Arrests in last 30 days
Name of PCP:
REASON FOR REFERRAL (check all that apply):
- Behavior/Conduct Challenges
- Emotional/Mental Illness
- Employment /Financial Instability
- Housing
- Medication Mismanagement
- Suicidal/Homicidal
- Relational Conflicts
- Social Skills
- Substance Abuse
- Community Living Skills
- Self Care Skills
- Independent Living Skills
- Sexual/Physical/Emotional Abuse
- Symptom Management
- Legal/Incarceration
SYMPTOMS AND BEHAVIORS/RISK BEHAVIORS (check all that apply):
- Anxiety/Panic
- Depressed
- Homicidal Ideations
- Hopeless/Helpless
- Self-Injurious Behavior
- Trauma-related
- Verbal/Physical Aggression
- Self-Care Deficit
- Social/Withdrawal
- Sexually Inappropriate
- Suicidal Ideations
- Stealing
- Property Destruction
- Impulsive/Manic Episode
- Irritable
- Lying/Manipulative
Suicide Risk
- Yes
- No
Danger to Self or Others
- Yes
- No
Urgent/Critical Medical Condition
- Yes
- No
Immediate Threat(s):
- Yes
- No
Past Psychiatric Admission(s):
- Yes
- No
Previous Outpatient Treatment
- Yes
- No
DSM V DIAGNOSES & RELEVANT MEDICATIONS:
Medications:
Axis I:
Axis II:
Axis III:
Axis IV:
Is there documentation attached to verify this diagnosis?
- Yes
- No
Is the client currently receiving therapy?
- Yes
- No
Referral Source Printed Name & Agency (IF APPLICABLE):
Signature:
Date of Referral:
Phone:
Email:
CHECK APPLICABLE:
- Verbal Approval from Therapist to refer identified client for Psychiatric Rehabilitation services secured.
- I am authorized or have been given authorization to give consent for Choice Community Health to collaborate with service providers to receive and verify the information on this form for screening assessment purposes, and to determine the appropriateness of services for above-referenced individual

PRP REFERRAL FORM

Psychiatric Rehabilitation Program

PRP REFERRAL FORM

REASON FOR REFERRAL (check all that apply):

SYMPTOMS AND BEHAVIORS/RISK BEHAVIORS (check all that apply):

DSM V DIAGNOSES & RELEVANT MEDICATIONS: