July 8, 2021 debby PRP REFERRAL FORM 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
