Psychiatric Rehabilitation Program Referral Form
My Empowering Impact
Client Contact Information
Check all that apply
*
Adult
Minor
Client Name
*
First Name
Last Name
Parent/Guardian Name (complete if client is 18 years or younger)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender/Sexual Orientation
*
Please Select
Male
Female
Transgender
Bi-sexual
Non-Binary
Other
Client Race/Ethnicity
*
Medicaid (Medical Assistance Number)
*
Social Security Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Diagnosis
*
Please Refer To Chart Below For Adult Dx.
If the client is an ADULT please complete this section, (If Not Applicable please mark Not Applicable)
*
Not Applicable
Housing Needs
Social Skills Limitataions
Substance Use Concerns
Safety Concerns in the Community
Need for Higher level of Mental Health Care
Cognitive limitations causing inability to secure financial assistance and/or gainful employment to support living in the community
Impulse Control Concerns
Independent Living Limitations
Medication Management Assistance
Marked inability to perform activities of daily living
Social Behaviors that results in impairments of ADLs
Inability to maintain employment
If the client is a CHILD/ADOLESCENT/MINOR please complete this section, (If Not Applicable please mark Not Applicable)
*
Not Applicable
Anger management
Risk for school disruption
Social Skills Limitations
Substance Use Concerns
Safety Concerns in the Community
Social Skills/Peer Interactions
Mentoring/Community Activity
Impulse Control Concerns
Housing/Independent Living Limitations
Medication Management Assistance
Marked inability to perform activities of daily living
Safety concerns for self and others
Inability to maintain employment
Please explain mental health issues that are impacting clients ability to function and need for Rehabilitation Services Requested
*
Has client recently been discharged from an outpatient Mental Health Facility/Hospital?
*
Please Select
YES
NO
UNKNOWN
Has the client been arrested in the past sixmonths?
*
Please Select
YES
NO
UNKNOWN
Is there a safety plan documented?
Please Select
YES
NO
UNKNOWN
Was the client hospitalized in the past 30 days?
Please Select
YES
NO
UNKNOWN
Is the client able to safely benefit from PRP services?
*
Please Select
YES
NO
UNKNOWN
Licensed Mental Health Professional (must be licensed to complete referral, if not supervisors' signature is required)
*
First Name
Last Name
Professional Credentials
*
Referring Provider/Agency Name
*
Referring Provider/Agency Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Supervisor Name
First Name
Last Name
Supervisor Credentials
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Licensed Mental Health Provider Signature
*
Please Upload any information applicable to this referral (Treatment Plans, Safty Plans, Medication etc...)
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