Adult PRP Referral Form for Mid Shore
  PRP Referrals Must be completed by the therapist referring the participant
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Email *
Date of Referral *
MM
/
DD
/
YYYY
Participant Name *
Date of Birth *
Age: *
Race *
Sex at Birth *
Gender Identity and Preferred Pronouns *
Home Address *
County
Clear selection
Contact Number *
Medicaid Number *
Email Address *
Referring Therapist Information
Name and Credentials of Therapist *
If LMSW or LGPC Please Provide the Name and Credentials of your Supervisor
Agency Name *
Phone number *
Fax Number *
Email Address *
Clinical Information
Reason for Referral *
Participant's Strength and Current Resources *
Goals of Requested Services *
Has a Mental Health Assessment and Treatment Plan Been Completed? (If Yes, A Copy Will Need to be Provided if Accepted Into the Program)   *
ICD-10 Information
Category A Diagnosis *
Category B Diagnosis *
Additional Diagnosis
Is the Participant Receiving Fully Funded DDA Benefits? *
Has the Participant Been Active in Treatment? *
Required
Length of Treatment *
Has Medication Been Prescribed to Support Mental Health? *
Required
If Yes, Please List the Name of the Prescriber
Risk
Are There any Risks for Aggressive Behavior, Suicide or Homicide? *
Required
If Yes, Please Explain
Is the Participant Coming Out of In-Patient or at Risk of going Into In-Patient? *
Required
If Yes, Please Explain
Is the Participant currently enrolled in Targeted Case Management *
If participant is currently involved with Targeted Case Management. Please explain how PRP support would add to the success and ability for client to maintain in current setting *
PRP services/referral has been explained to participant or parent/guardian of participant *
Is the Participant currently Enrolled/Authorized for another PRP? *
 By signing this I acknowledge that I am Referring This Participant for PRP Services and This is My Electronic Signature *
Required
Name and Credentials *
Please note the turnaround time is 1 to 2 business days to received confirmation of receipt of referral. If you have not received confirmation of receipt please contact Crystal Miller directly at: cmiller@wraparoundmd.com
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