PRP Referral Form | Resolution Health and Wellness Center

Referring Agency / Individual Name *

Phone #

Email Address

Fax #

Street Address

City

ZIP / Postal Code

Date of Referral

Client Name *

Date of Birth

Gender

MaleFemale

Age

MA #

MCO

Social Security #

Type of Insurance

MedicaidMedicareCommercial Insurance

Is there a current or previous substance use?

YesNo

If yes, currently in treatment?

YesNo

Phone Number

Email Address

Home Address

State

ZIP

Is the client homeless?

YesNo

Mental Health Evaluation / AssessmentIndividual TherapyGroup TherapyFamily TherapyPsychiatric Rehabilitation Services (PRP)Substance Abuse Services (circle one): IOP / OP Counseling, DUI/DWI GroupsResidential Housing ServicesPsychiatric Services / Medication Management / Evaluation

295.90 / F20.9 – Schizophrenia295.40 / F20.81 – Schizophreniform Disorder295.70 / F25.0 – Schizoaffective Disorder, Bipolar Type295.70 / F25.1 – Schizoaffective Disorder, Depressive Type298.8 / F28 – Other Specified Schizophrenia Spectrum and Other Psychotic Disorder298.9 / F29 – Unspecified Schizophrenia Spectrum and Other Psychotic Disorder297.1 / F22 – Delusional Disorder296.33 / F33.2 – Major Depressive Disorder, Recurrent Episode, Severe296.34 / F33.3 – Major Depressive Disorder, Recurrent Episode with Psychotic Features301.22 / F21 – Schizotypal Personality DisorderF31.0 – Bipolar I Disorder, Current or Most Recent Episode Hypomanic296.43 / F31.13 – Bipolar I Disorder, Current or Most Recent Episode Manic, Severe296.44 / F31.2 – Bipolar I Disorder, Current or Most Recent Episode Manic with Psychotic Features296.53 / F31.4 – Bipolar I Disorder, Current or Most Recent Episode Depressed, Severe296.54 / F31.5 – Bipolar I Disorder, Most Recent Episode Depressed with Psychotic FeaturesF31.63 – Bipolar I Disorder, Mixed, Severe, Without Psychotic FeaturesF31.64 – Bipolar I Disorder, Mixed, Severe, With Psychotic Features296.40 / F31.9 – Bipolar I Disorder, Current or Most Recent Episode Hypomanic, Unspecified296.70 / F31.9 – Bipolar I Disorder, Current or Most Recent Episode Unspecified296.80 / F31.9 – Unspecified Bipolar and Related Disorder296.89 / F31.81 – Bipolar II Disorder301.81 / F60.3 – Borderline Personality Disorder

Activities of Daily LivingAnger / Temper / Conflict ResolutionAssertiveness / Self-esteemCommunity ActivityFamily / Natural SupportsFinancesHome / HousingSelf-Care SkillsSafety to Self / OthersSchool PerformanceSexual IssuesSocial Skills / Peer InteractionSubstance Abuse IssuesCoping SkillsTraumaMedication Compliance SkillsVocational SkillsLeisure SkillsWork / Job PerformanceLegal Issues (# of arrests)Money ManagementDietary / Food PreparationCrisis Management SkillsPhysical Health

In Current Treatment?

YesNo

Treating Psychiatrist

Organization

Address

Phone Number

Mental Health Therapist

Organization

Address

Phone Number

Referred By

Date

Clinician's Signature

Date

NPI

Supervisor's Name

Credentials

Supervisor's NPI

Referring Provider Signature

Title

Date

PSYCHIATRIC REHABILITATION PROGRAM (PRP) REFERRAL