Adult PRP Referral Home Optum Adult PRP Referral Adult PRP Referral Adult PRP Referral (PDF) or (Word) Consumer Name: * Guardian Name: * Does the Parent/Guardian have legal custody (if minor)? * YesNo Address:* City: State: Zip: Home Phone:* Cell #* Medical Assistance/Medicaid #: Is the individual currently receiving SSI/SSDI YesNo Is the individual eligible for full funding for Developmental Disabilities Administration services YesNo Is the primary reason for impairment due to an organic process of syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder YesNo Has the individual been found not competent to stand trial or not criminally responsible and is receiving services recommended by a Maryland Dept of Health Evaluator YesNo ICD-10 Primary Diagnosis Code Diagnosing Clinician and Title Duration of current episode of treatment provided to this individual Less than one monthOne visit in the last three monthsTwo or more visits in the last three months Current frequency of treatment provided to this individual At least 1x/weekAt least 1x/2 weeksAt least 1x/monthAt least 1x/3monthsAt least 1x/6months Has the individual received PRP services from at least one other PRP within the past year? YesNo REFERRAL SOURCE Agency Name: Therapist Name& Credentials * Address: * Phone #:* Fax #: Email Address:* Criteria for admission (CHECK ALL THAT APPLY AND COMMENT WHERE CHECKED) Marked inability to establish or maintain competitive employment Marked inability to perform instrumental activities of daily living (e.g: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation and money management) Marked inability to maintain personal support system Deficiencies of concentration/persistence/pace leading to failure to complete tasks Unable to perform self-care (hygiene, grooming, nutrition, medical care, safety) Marked deficiencies in self direction, shown by inability to plan, initiate, organize and carry out goal directed activities. Marked inability to procure financial assistance to support community living Duration of impairments (check off all that applies) Marked functional impairment has been present for less than 2 yearsMarked functional impairment has been limited to less than 3 of the above listed areasHas demonstrated marked impairment functioning primary due to a mental illness in at least three of the areas listed above at least 2 yearsHas demonstrated impaired role functioning primarily due to a mental illness for at least 3 years Licensed Provider Completing this Application: Print Name: * Signature * Date *
