Submit your Referrals Form

DATE

PROGRAM: PRP ON/OFF SITE

Clients Name *

DOB

Age

Address *

County

State

Zip

Home Phone *

Other Phone *

Gender

Male

Female

Social Security #

MA #

EthniCounty

Marital Status

Veteran

Yes

No

Hurricane Katrina Victim

Yes

No

LEGAL CUSTODIAN (for minors/dependents)
*NOTE: Court documentation regarding custody status must be included with referral form.

Primary DSS or DJS Custody?

Yes

No

N/A

Court ordered attached to referral(if yes)

Name *

Relationship

Work Phone # *

Home #

Address

County

State

Zip

REFERRAL SOURCE

Agency

Contact Person/Credentials

Phone

Ext.

Fax

Address

County

Zip__

(Referral to PRP must be active in mental health treatment and approved by that provider)

MOST RECENT MENTAL HEALTH TREATMENT

Currently being treated?

Yes

No

Agency

Therapist Name/Credentials

Address

County

Zip

Phone

Ext.

Other Phone Number

Fax

Therapist Email Address *

DSM IV DIAGNOSIS *NOTE:MUST INCLUDE A COMPLETE AXIS I-V*

AXIS I

AXIS IV

AXIS V

Highest Past Year

AXIS II

Diagnosed by

AXIS III

Date Diagnosed

Medications

Presenting Complaint

Family Function/History

Problems with Family Relations?

Custody/Placement?

Living Situation?

***PLEASE SUBMIT REPORTS OF TREATMENT PLANS, TESTS AND PRIOR EVALUATIONS**VOCATIONAL/SCHOOL/EMPLOYMENT

Name of School(Highest Grade Completed)

Name of Current Employer

# of Current Hours Worked

# of Yrs at Current Employer

How many days absent within past month for any reason?

Time suspended?

Problems with friendship/Social Relations?

School/Work Problems?

LEGAL HISTORY

How many times arrested in the last 6 months?

Currently on Probation?

Yes

No

History of Abuse (verbal, sexual, physical, emotional, domestic, violence)

Histoy of Substance Abuse (note if current usage)

Histoy of Suicidal/Homicidal attempts or ideation

History of Hospitalization and/or residential placement

Dates

Facility

Reason for Admission

PRP Criteria for Adminssion
Unable to care for physical needs in age appropriate manner
Severely impaired concentration or thought organization
Requires help in basic living skills
Inability to establish or maintain personal social support system
Inappropriate social behavior causing severe problems with peer relationships and/or family
A clear, current threat to the individual's ability to be employed or attend school
An emerging/impeding risk to the safety or property of the individual or of others
Less treatment was not sufficient to prevent deterioration and/or stabilized the disorder
If transitioning from inpatient to community setting, there is clinical evidence that less intensive treatment will not be sufficient

Identify Goals, Needs, Functional Domains & or Skills to be addressed:

Entitlements	Educational Support	Leisure Skills
Health	Employment Support	Housing Support
Social & Community	Selft Care	Mobility
Independent Living	Other