Adult Referral Page | Transform A Nation

Adult
Referral Form

Adult Psychiatric Rehabilitation services are for adults with serious mental illness or emotional disturbance who need rehabilitation services to reduce symptoms and restore the consumer back to an appropriate functional level. Some of the services offered are social skills, self-care skills, anger management, conflict resolution skills etc...

Referral Status:

Initial Referral

RE-Referral

Client First Name

Client Last Name

Street Address

City

Postal / Zip code

Legal Guardian (If Applicable)

Relationship to Client (If Applicable)

Medical Assistance Number

Social Security Number

Date of Birth

Age

Phone

Secondary Phone

Client's Email Address

Highest Level of Education

Does the consumer receive Social Security Disability?

Yes

Has the consumer had any psychiatric hospitalizations within the last 3 months?

Yes

Has the consumer been released from inpatient, a day hospital, or residential treatment within the past 3 months?

Yes

Has medication been considered to combat symptoms?

Yes

DSM-V Diagnosis

Diagnosis F-Code and Name 1:

Diagnosis Diagnosis F-Code and Name 2:

Diagnosis Code 2:

Diagnosis Diagnosis F-Code and Name 3:

Diagnosis Diagnosis F-Code and Name 4:

Diagnosis given by (Name and credentials):

Diagnosis Date

Medical Necessity Criteria

Within the Past 3 months, the individual's emotional disturbance resulted in:

Employment-Marked inability to establish or maintain independent competitive employment, characterized by an established pattern of unemployment, underemployment, or sporadic employment that is primarily attributable to a diagnosis of serious mental illness. Describe specific behavioral health barriers (if none, write N/A) :

Daily Living Impairments- Marked inability to perform instrumental activities of daily living (shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management) that is primarily attributable to a diagnosed serious mental illness. Describe specific behavioral health barriers (if none, write N/A) :

Lack of Natural/Social Supports- Marked inability to establish or maintain a personal support system, characterized by social withdrawal or isolation, interpersonal conflict, or social behavior (other than criminal behavior) that is not easily tolerated in the community and primarily attributable to a diagnosed serious mental illness. Describe specific behavioral health barriers (if none, write N/A) :

Impaired Concentration-Marked or frequent deficiencies of concentration, persistence or pace that is primarily attributable to a serious mental illness resulting in a failure to complete in timely manner tasks commonly found in work, school, or home settings, which requires intervention by the behavioral health system. Describe specific behavioral health barriers (if none, write N/A) :

Poor Self-Care-Marked inability to perform or maintain self-care (hygiene, grooming, nutrition, medical care, personal safety) that is primarily attributable to a serious mental illness. Describe specific behavioral health barriers (if none, write N/A) :

Impaired Self-Direction- Marked deficiencies in self-direction, characterized by an inability to independently plan, initiate, organize, and carry out goal-directed activities that is primarily attributable to a serious mental illness. Describe specific behavioral health barriers (if none, write N/A) :

Financial Instability- Marked inability to obtain financial assistance to support community living, which inability is primarily attributable to a serious mental illness. Describe specific behavioral health barriers (if none, write N/A) :

Clinical Admission Criteria

Has consideration been given to using peer supports and other informal supports such as family? (If yes, list attempts and outcomes of any efforts to serve this individual through less formal means such as peer supports, or family)

List specific ways in which PRP services are expected to help this individual:?

Does the client need a more intensive level of care (residential treatment, inpatient psychiatric)?

Yes

Does the consumer have an active therapist?

Yes

Current frequency of treatment provided to this individual:

Have less intensive levels of treatment, etc. (therapy, medication, family, or peer support) been determined to be unsafe or unsuccessful for the consumer?

Yes

Referring Clinician

Referring Agency:

Street Address

City

Postal / Zip code

Referring Clinician's Name & Credentials:

Referring Clinician's Email Address:

Phone Number:

Fax Number:

Supervising Clinician's Name and Credentials (if applicable):

Referring Clinician's Electronic Signature Attestation*

I am authorized or have been given the authorization to give consent for the TAN PRP Team to collaborate with service providers to receive and verify the information on this form for screening assessment purposes and to determine the appropriateness of services for the above-referenced individual.

Referring Clinician's Electronic Signature

Date of Referral:

Adult Referral Form

DSM-V Diagnosis

Medical Necessity Criteria

Clinical Admission Criteria

Referring Clinician

Adult
Referral Form