Cognitive Elevations: Referral Psychiatric Rehabilitation Program - Minors (PRP-M) "*" indicates required fields Step 1 of 7 14% PRP MinorsDate* Month Day Year Client Name* First Last Date of Birth* Month Day Year Client Address* Street Address Address Line 2 City 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 State ZIP Code PhoneSocial Security # Medical Assistance # Email Gender male female Ethnicity: Marital Status: single married divorced Religion: Client’s school Current Grade Number of Arrest in last 30 days? PRP Minors PRP Minors REFERRAL SOURCE: Agency: Contact Person: Therapist Name: Email Address: PhoneExt: Fax #Address PRP Minors PRP Minors DSM-V BEHAVIORAL DIAGNOSIS: A minor must have a behavioral diagnosis and be referred by a Licensed MH Professional to be PRP eligible BehavioralDiagnostic Category: Code: Description: Diagnostic Category: Code: Description: Diagnostic Category: Code: Description: MedicalDiagnostic Category: Code: Description: Diagnostic Category: Code: Description: Diagnostic Category: Code: Description: Social elements Impacting Diagnosis (Check all that apply) None Problems with access to healthcare services Housing problems (not homelessness) Problems related to the social environment Education Problems Problems related to interactions with legal system/crime Occupational problems Homelessness Financial problems Problems with primary support groups Other psychological and environmental problems Unknown Functional Assessment Date of Diagnosis: Month Day Year Assessment Measure/Score: Measure: Name and Title: PRP Minors PRP MinorsREASON 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 PRP Adult 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* CommentsThis field is for validation purposes and should be left unchanged.
