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FOR ADULTS ONLY!! Mental Health Provider Referral to the Community Wellness Center Psychiatric Rehabilitation Program (PRP)

Referring Professional Information

Referral date*
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In addition to psychiatric rehabilitation program (PRP) and behavioral health home (BHH) services, what other services would the client need? (please check all that apply)
Client date of birth
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Client gender
Is the client considered a minor (under 18 years of age)?*
1. Is the client homeless?*
2. Is the Primary reason for the individual' impairment due to an organic process or syndrome intellectual disability, a neurodevelopment disorder or neurocoginitive disorder?*
3. To the best of your knowledge does the client suffer from any communicable diseases (HIV, Hepatitis, TB, MMRV, etc.)?*
4. Is the client on any medications to include psychotropic and somatic medications?*
5. Has the client within the past year been discharged from an inpatient psychiatric facility or hospital?*
6. Has the client been arrested in the past six months?*
8. Is the client currently employed?*
9. Is the client currently receiving mental health treatment or psychotherapy from a therapist or psychiatrist?*
10. Is the individual currently enrolled in SSI or SSDI?*
11. Does the nature of the individual’s functional impairments and/or skill deficits can be effectively remediated through specific, focused skills-training activities designed to develop and restore (and maintain) independent living skills to support the individual’s recovery?*
12. Does the Individual require a more intensive level of care?*
13. Have all less intensive levels of treatment have been determined to be unsafe or unsuccessful?*
14. Have peer or natural support alternatives been considered or attempted, and/or are insufficient to meet the need for specific, focused skills training to function effectively?*
15. Participant is fully eligible for Developmental Disabilities Administration funded services?*
16. Primary reason for the participant’s impairment is due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder, or neurocognitive disorder?*
17. The participant has been judged not to be in sufficient behavioral control to be safely or effectively served in PRP?*
18. The participant lacks capacity to benefit from PRP as a result of the level of cognitive impairment, current mental status or developmental level which cannot be reasonably accommodated within the PRP?*
19. The referral source is in some way is paid by the PRP program or receives other benefit from PRP program?*