Minor PRP Referral

Consumer Name: *

D.O.B: *

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 eligible for full funding for Developmental Disabilities Administration services?
YesNo

Have family or peer supports been successful in supporting this youth
YesNo

No Is the primary reason for the youth’s impairment due to an organic process of syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disor
YesNo

ICD-10 Primary Diagnosis *

Code Diagnosing Clinician and

Clinician Agency

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

How long has youth been engaged in active, documented outpatient treatment? *
Less than one monthOne visit in the last three monthsTwo or more visits in the last three months

Is the youth transitioning from an inpatient, day hospital or residential setting to the community setting? *
YesNo

Does the youth have a Target Case Management referral or authorization? *
YesNo

Has medication been considered for this youth? *
Not consideredConsidered and Ruled Out Initiated and WithdrawnOngoingOther Comments:

Agency Name: *

Contact Person Name: *

Phone #: *

Fax #: *