Cognitive Elevations: Referral Psychiatric Rehabilitation Program – Adults (PRP-A) "*" indicates required fields Step 1 of 7 14% PRP AdultDate* Month Day Year Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Social Security # Birth of Date* Month Day Year Age* Medicaid # (if known) Marital status* Single Divorced Widowed Significant other Employed* Yes No Has this individual received PRP services before?* Yes No Program Name: Dates of service (if known) Month Day Year PRP Adult PRP AdultCurrent Diagnosis* 296.20-296.36 Major Depressive Disorder 296.31 Major depressive disorder, Recurrent episode, Mild 296.32 Major depressive disorder, Recurrent episode, Moderate 296.33 Major depressive disorder, Recurrent episode, Severe 295.90 Schizophrenia 295.70 Schizoaffective disorder, Bipolar type 295.70 Schizoaffective disorder, Depressive type 296.41-296.44 Bipolar Disorder 296.51 Bipolar I disorder, Current or most recent episode depressed, Mild 296.52 Bipolar I disorder, Current or most recent episode depressed, Moderate 296.53 Bipolar I disorder, Current or most recent episode depressed, Severe 296.41 Bipolar I disorder, Current or most recent episode manic, Mild 296.42 Bipolar I disorder, Current or most recent episode manic, Moderate 296.43 Bipolar I disorder, Current or most recent episode manic, Severe PRP Adult PRP AdultHas this individual been impaired for at least 2 years in any of the following categories? Please check at least 3 of the following categories if applicable* Marked inability to establish or maintain independent competitive employment: characterized by an established pattern of unemployment, underemployment, or sporadic employment that is primarily attributable to a diagnosed Page 16 of 47 BH2564_01/2020 serious mental illness, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems. Marked inability to perform instrumental activities of daily living (shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management) that is primarily attributable to a diagnosed serious mental illness, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems. Marked inability to establish or maintain a personal support system, characterized by social withdrawal or isolation, interpersonal conflict, or social behavior (other than criminal behavior) that is not easily tolerated in the community and primarily attributable to a diagnosed serious mental illness, and which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems Marked or frequent deficiencies of concentration, persistence or pace that is primarily attributable to a serious mental illness resulting in a failure to complete in a timely manner tasks commonly found in work, school, or home settings, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations Marked inability to perform or maintain self-care (hygiene, grooming, nutrition, medical care, personal safety) that is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations Proper interaction with peers Marked deficiencies in self-direction, characterized by an inability to independently plan, initiate, organize, and carry out goal-directed activities that is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations. Marked inability to procure financial assistance to support community living, which inability is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems. PRP Adult PRP AdultDIAGNOSED BY:* DIAGNOSIS DATE* Month Day Year Name of Facility or Program* Program /Facility Address Program /Facility Phone* Program /Facility Email PRP Adult PRP AdultREASON FOR REFERRAL: Physically aggressive Verbally aggressive Hyperactive Depressed mood Impulsive Running away Frequent contact with law enforcement Self injurious Suicide ideation Homicidal Ideation Oppositional defiant Separation anxiety Has experienced trauma Challenges authority Self Care deficit PRP Adult PRP AdultSelf-Care Skill personal hygiene/grooming dressing self toileting nutrition/dietary planning following routines (bed, school) self-administration of meds Semi-Independent Living Skills taking care of belongings maintaining living area safety skills money management mobility skills accessing entitlements interactive skills with peers interactive skills with family interactive skills with adults community integration participation in activities developing natural supports PRP Adult PRP Adult LICENSED MENTAL HEALTH PROFESSIONAL PROVIDING REFERRAL: Name & Credentials: Agency/Organization Street Address: Phone Number:City, State, Zip E-Mail Address: Mental Health Treatment Currently Being Provided: Outpatient Mental Health Services Inpatient Mental Health Services Residential Treatment Center Terms Referral Authorizations I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to David’s Lost Clinical Services. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to David’s Lost Clinical Services. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to David’s Lost Clinical Services. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. Typing my name below serves as my digital signature. Referral Authorizations* I agree to the referral authorization terms Digital Signature* NameThis field is for validation purposes and should be left unchanged.
