Minor Referral Page | Transform A Nation

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Minor
Referral Form

Psychiatric Rehabilitation services are for children, adolescents, and young 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

Initial Referral

RE-Referral

Client First Name

Client Last Name

Gender

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

No

REASON(S) FOR REFERRAL (Check all that apply) * Required

Adaptive Resources

Crisis Intervention

Dangerous Behaviors

Educational/Vocational Training

Health Promotion

Independent Living Skills

Promotion of Wellness, Self Management & Recovery

Recovery Challenges

Psychiatric Inpatient /Detention Center Support

Self-Care Skills

Social Relationships & Leisure Activities

Social Skills

PLEASE SELECT ALL SYMPTOMS AND BEHAVIORS /RISK BEHAVIORS THE CLIENT MAY BE EXPERIENCING (check all that apply):

Anxiety/Panic

Attachment Problems

Bullied by Others

Depressed

Disruptive Behaviors

Fire Setting

Homicidal Ideations

Hopeless/Helpless

Hyperactive

Impulsive

Irritable

Isolation

Low Self-Esteem

Lying/Manipulative

Manic Mood

Obsession/Compulsion

Oppositional Defiant

Physical Aggression

Poor Concentration

Poor Hygiene

Problem Sleeping

Property Destruction

Refusal to Comply w/Rules or Request

Self-Care Deficit

Running Away

Self-Injurious Behaviors

Seperation Problems

Sexually Inappropriate

Social/Withdrawal

Stealing

Sudden Change in Mood Behavior

Suicidal Ideations

Trauma-related

Truancy

Verbal Aggression

IS THE CONSUMER CURRENTLY RECEIVING * Required

Targeted Case Management

Inpatient

Mobile Treatment Services (MTS/ACT)

MH-Residential Treatment Center (RTC)

Residential SUD Treatment Level 3.3 and higher

SUD IOP/2.1

MH IOP/PHP

Residential Crisis

Not Applicable

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

Yes

No

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

Yes

No

Has medication been considered to combat symptoms? *

Yes

No

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:

A clear, current threat to the youth’s ability to be maintained in their customary setting (if none, write N/A):

An emerging risk to the safety of the youth or others (if none, write N/A) :

Significant psychological or social impairments causing serious problems with peer relationships and/or family members (if none, write N/A) :

What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth’s symptoms and functional behavioral impairments resulting from mental illness?

Clinical Admission Criteria

How will PRP serve to help this youth get to age-appropriate development, more independent functioning, and independent living skills?

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

Yes

No

Does the consumer have an active therapist? *

Yes

No

Current frequency of treatment provided: *

At least 1x/week

At least 1x/2 weeks

At least 1x/month

At least 1x/3 months

At least 1x/6 months

The youth has been engaged in active, documented outpatient treatment for: *

Less than a month

Between one and three months

Six months or more

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

Yes

No

Referring Clinician

Referring Agency:

Street Address

City

Postal / Zip code

Referring Clinician Name & Credentials:

Referring Clinician's Email Address:

Phone Number:

Fax Number:

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

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 Attestation*

Referring Clinician's Electronic Signature

Date of Referral:

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

Transform A Nation

info@transformanation.org (email)

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

©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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