(301) 441-2368
(301) 441-2368
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Home
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Grace And Mercy Health Services
(Health & Nursing Services)
Residential Services
Skilled Nursing
Personal Care
Companion Care
Homemaking Services
Activities of Daily Living (ADLs)
Developmental Disabilities Services (DDS)
Grace & Mercy Community Services
(Behavioral Health Services)
Outpatient Mental Health Center (OMHC)
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Intensive Outpatient Program (IOP) – SUD Level 2.1
Psychiatric Rehabilitation Program (PRP) – Adults & Minors
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Referral Form
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Referral Date
MM slash DD slash YYYY
Referring Organization
Phone #
Fax #
Email
CLIENT INFORMATION
Name
Address
Phone Number
D.O.B
Age
Gender
Race
SS#
Medical Assistance#
Highest Grade Completed
Currently Employed
Yes
No
Reason for PRP Referral (Check all that apply)
Conflict w/family
Depression
Suicidal / Homicidal
Violence
Somatic Issues
Physical Issues
Behavioral Issues
Prevention of Illness
Sexual Abuse
Legal Issues
Medication Compliance Mobility/Transportation
Education
Social Leisure
Peer Relations
Employment
Academic Problems
Anger Management
Other
Other: (Please Specify)
Signs/Symptoms
Difficulty Sleeping
Fatigue/ Lack of Sleep Dry mouth, stomach pains, vomiting, diarrhea
Feeling of worthlessness, self-hate, & guilt.
Agitation, restlessness, & irritability
Inactivity & withdrawal from typical pleasurable activities.
Feelings of hopelessness & helplessness
Excessive Worry
Difficulty Relaxing
Shortness of breath
Dizziness, headache, vertigo, or numbness of the skin Jumbled/Illogical Speech
Muscle ache & tension, restlessness
Obsessive/ Compulsive behavior
Distress in social situations
Change in weight or appetite
Speaking slowly in monotones
Inappropriate excitement
Elevated/ Elated Mood
Hallucinations/ Delusions
Blunted, Flat or Inappropriate Emotion
Other
Other: (Please Specify)
Axis 1: (Please check one or more of the following that apply)
(Note: To qualify for PRP services, the client must meet the criteria of at least one of the Priority Population diagnosis listed below.)
F20.9 Schizophrenia
F20.81 Schizophreniform Disorder
F25.0 Schizoaffective Disorder, Bipolar Type
Depressive Type
F25.1 schizoaffective disorder
F28 Other Specified Schizophrenia Spectrum & other Psych. D/O F29
Unspecified Schizophrenia Spectrum & other Psych. D/O
F31.5 Bipolar I D/O, Most Recent Episode Depressed, with Psych. Feat
F31.0 Bipolar I D/O, Current or Most Recent
Episode Hypomanic
F31.9 Unspecified Bipolar and Related Disorder
F33.2 Major Depressive Disorder
Recurrent Episode, Severe
F33.3 Major Depressive Disorder, Recurrent, with Psych Features
F22 Delusional Disorder
F31.9 Bipolar I D/O, Current/Most Most Recent Episode Hypomanic, Unspecified
F31.81 Bipolar II Disorder
F21 Schizotypal Personality Disorder
F60.3 borderline personality disorder
Other
Other: (Please Specify)
Axis II
Axis III
Axis IV
Axis V
Summary (Reason for Referral)
Clinician Name
Credentials
Clinician Signature
Date
MM slash DD slash YYYY
***Only a CRNP-PMH, Licensed Psychologists, LCSW-C, LCPC, APRN-PMH, LCMFT, LCADC, LCPAT, LGMFT, LGADC, and LGPAT may make a referral for PRP***
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