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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: Required
Does the consumer receive Social Security Disability?
REASON(S) FOR REFERRAL (Check all that apply) Required
PLEASE SELECT ALL SYMPTOMS AND BEHAVIORS /RISK BEHAVIORS THE CLIENT MAY BE EXPERIENCING (check all that apply):
IS THE CONSUMER CURRENTLY RECEIVING Required
Has the consumer had any psychiatric hospitalizations within the last 3 months?
Has the consumer been released from inpatient, a day hospital, or residential treatment within the past 3 months?
Has medication been considered to combat symptoms?

DSM-V Diagnosis

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

Does the client need a more intensive level of care (residential treatment, inpatient psychiatric)? Required
Does the consumer have an active therapist? Required
Current frequency of treatment provided to this individual: Required
Duration of the current episode of treatment provided to this individual: Required
Have less intensive levels of treatment, etc. (therapy, medication, family, or peer support) been determined to be unsafe or unsuccessful for the consumer? Required

Referring Clinician

Referring Clinician's Electronic Signature Attestation*

988 Suicide and Crisis Lifeline - If you or someone you know is struggling or in crisis, help is available.

Call or text 988 or chat 988lifeline.org

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410-469-9145 (office)

410-415-3606 (office)

443-438-4236 (fax)

901 North Milton Avenue, Suite 320

Baltimore, MD. 21205
Monday -Thursday 9:00am-6:00pm, Friday 9:00am - 3:00pm, 

Saturday By Appointment Only

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©2021 by Transform A Nation
FEE STRUCTURE
Services provided will be on a fee-for-service basis.
Transform A Nation accepts only Medical Assistance/Medicaid.
Created by Blue Rain World, LLC

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