PRP REFERRAL FORM
This form may be used to make a referral to Advocate’s Psychiatric Rehabilitation Program.
Instructions: Please print legibly and fax completed form, along with any attachments, (current Psychiatric
Evaluation, Psychiatrist Referral Form and/or other medical records). A cover page is not required.
Fax completed form and any attachments to: 800-372-0799
Referral Source (Please complete this section by entering your contact information below.)
Your First Name Your Last Name (Include your credentials, if applicable)
Your Company (if applicable, enter the name of the company you work for.)
Your Address
City
Your Phone
Your Fax
Your Email
State
Zip Code
Your Relation to the Consumer Being Referred
(Please select the category which best describes your relation to the person being referred.)
Primary Care Physician
Psychiatrist
Mental Health Case Manager
Substance Abuse Provider
Psychologist
Medical Case Manager
Psychiatric Nurse
RN
Care Manager - APS
Therapist
Other:________________________
Consumer’s Psychiatrist (Please enter the contact information for the Consumer’s psychiatrist.)
First Name
Last Name
Company (if applicable, enter the name of the company the psychiatrist works for.)
Address
City
Phone Fax
Email
Advocate Support Services, Inc.
PRP_Referral_Form_6-22-09
1783 Forest Drive, #251 Annapolis, MD 21401
T 866-277-2080 F 800-372-0799
State
Zip Code
www.AdvocateSupport.com
Page 1 of 7
PRP REFERRAL FORM
Consumer's Contact & Demographic Information
Please provide information about the person you are referring below.
First Name
MI
Last Name
Street Address (Include house number and, if applicable apartment number.)
City
Primary Phone
County Secondary Phone
State
Alternate Phone
Zip Code
Does the Consumer have a legal guardian or custodian?
No
Yes
Name of Guardian/Custodian
Type of Guardianship
Phone
Please Provide the Consumer’s Social Security Number and Date of Birth Below. Maryland Mental
Hygiene Administration requires Advocate to provide the Consumer's SSN when requesting authorization for
services. Consumer MUST be 18 years of age or older to be admitted.
Consumerʼs SS#
Consumerʼs Date of Birth
Consumer's Gender
Male
Consumer's Ethnicity
(Please Indicate Consumer's Ethnicity.)
Not of Hispanic or Latino Origin
Hispanic/Mexican
Female
Unknown
Consumer's Race (Indicate Consumer's Race.
Hispanic/Puerto Rican
American Indian or Alaskan Native
Hispanic/Cuban
Hispanic/Spanish
Asian
Black or African American
Hispanic/South or Central American
Other Spanish Culture of Origin
Native Hawaiian or Other Pacific
Islander
White
Not Applicable
At least one is required. Choose all that apply)
Consumer's Marital Status
Single
Not Available
Married
Divorced
Unknown
Advocate Support Services, Inc.
PRP_Referral_Form_6-22-09
1783 Forest Drive, #251 Annapolis, MD 21401
T 866-277-2080 F 800-372-0799
www.AdvocateSupport.com
Page 2 of 7
PRP REFERRAL FORM
Highest Education Level Consumer has Completed
(Select the choice which most accurately reflects the
highest level of education the Consumer has completed.)
First Grade
Second Grade
Current Employment Status
(Select the choice which most accurately describes the
Consumer's current employment status.)
Competitively Employed Full or Part Time
Supported Employment Full or Part Time
Unemployed - Looking for Work
Third Grade
Fourth Grade
Fifth Grade
Retired
Sheltered Employment
Sheltered Workshop
Sixth Grade
Seventh Grade
Homemaker
Student
Eighth Grade
Ninth Grade
Tenth Grade
Volunteer
Disabled - Not in Workforce
Not Seeking to Work
Eleventh Grade
High School
Not Available
GED
Community College (i.e., Associate Degree)
Four Year College
Vocational Training Program
Graduate School
Is the Consumer a Hurricane Victim?
No
Is the Consumer a veteran?
Yes
No
Is the Consumer a veteran of Iraq or
Afghanistan?
Yes
Yes
No
Maryland Medicaid/Medical Assistance
(Indicate whether or not the Consumer has an active Maryland Medicaid/Medical Assistance Number.)
Yes
No
Consumer's Maryland Medicaid/Medical Assistance Number
Please enter the Consumer's Maryland Medicaid/Medical Assistance Number.
Consumerʼs Medicaid Number
Name & Phone of MCO
Please provide the name and phone number of the Consumer's Manage Care Organization, if applicable
Name of Consumerʼs Managed Care Company
MCO Phone
Name & Phone of PCP
Please enter the name and phone number of the Consumer's Primary Care Physician, if available.
Name of Consumerʼs Primary Care Physician
Advocate Support Services, Inc.
PRP_Referral_Form_6-22-09
1783 Forest Drive, #251 Annapolis, MD 21401
PCP Phone
T 866-277-2080 F 800-372-0799
www.AdvocateSupport.com
Page 3 of 7
PRP REFERRAL FORM
Consumer's Multi-axial Assessment & Medications
Please select the Consumer's current Primary Axis I Diagnosis from this list. If the Consumer has a primary Axis I
diagnosis which is NOT listed, he/she does not meet Maryland Mental Hygiene criteria for Psychiatric
Rehabilitation Services in Maryland.
Primary Axis I Diagnosis
295.10 Schizophrenia, Disorganized Type
295.20 Schizophrenia, Catatonic Type
295.30 Schizophrenia, Paranoid Type
295.40 Schizophreniform Disorder
295.60 Schizophrenia, Residual Type
295.70 Schizoaffective Disorder
295.90 Schizophrenia, Undifferentiated Type
296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic Features
296.34 Major Depressive Disorder, Recurrent, Severe With Psychotic Features
297.1 Delusional Disorder
298.9 Psychotic Disorder, NOS
298.9 Psychotic Disorder, NOS
301.22 Schizotypal Personality Disorder
301.83 Borderline Personality Disorder
296.43 Bipolar I Disorder, Most Recent Episode, Manic, Severe Without Psychotic
Features
296.44 Bipolar I Disorder, Most Recent Episode, Manic, Severe With Psychotic Features
296.53 Bipolar I Disorder, Most Recent Episode, Depressed, Severe Without Psychotic
Features
296.54 Bipolar I Disorder, Most Recent Episode, Depressed, Severe With Psychotic
Features
296.63 Bipolar I Disorder, Most Recent Episode, Mixed, Severe Without Psychotic
Features
296.64 Bipolar I Disorder, Most Recent Episode, Mixed, Severe With Psychotic Features
296.80 Bipolar Disorder, NOS
296.89 Bipolar II Disorder
Other Axis I Diagnoses
Please list all other current Axis I Diagnoses.
ICD-9 Code
Advocate Support Services, Inc.
PRP_Referral_Form_6-22-09
Description
1783 Forest Drive, #251 Annapolis, MD 21401
T 866-277-2080 F 800-372-0799
www.AdvocateSupport.com
Page 4 of 7
PRP REFERRAL FORM
Axis II Diagnoses
Please list all current Axis II Diagnoses.
ICD-9 Code
Description
Axis III Diagnoses
Please list all Axis III Diagnoses.
Axis III
Axis IV - Psychosocial Stressors:
None/NA
Mild
Moderate
Severe
Problems in Family Relations
Problems in Friendship/Social Relations
Legal Issues
Social/Work Problems
Custody/Placement Issues
Financial Difficulties
Problems in Living Situation
Physical Health
Axis V - GAF
Please enter the Consumer's current, or most recent GAF score.
Diagnosis Source, Name & Date
Please indicate the source of the diagnoses you provided in this
section. (name, credentials, title and date of diagnosis)
Name of person who made the above diagnoses
Advocate Support Services, Inc.
PRP_Referral_Form_6-22-09
1783 Forest Drive, #251 Annapolis, MD 21401
T 866-277-2080 F 800-372-0799
Date of Dx
www.AdvocateSupport.com
Page 5 of 7
PRP REFERRAL FORM
Medications
Please list all known medications currently prescribed to Consumer. If Consumer is not prescribed any
medications, please indicate "none".
Does the Consumer take medications as
prescribed?
Yes
No
No
Unknown
Does the Consumer received mental health
services for the past 2 years?
Yes
No
Is the Consumer currently receiving SSDI for
mental health reasons?
Yes
No
Is the Consumer homeless within the state of
Maryland?
Yes
No
Was the Consumer released from prison, jail, or a
Department of Correction facility
within the last 3 months?
Yes
No
Was the Consumer discharged from a Maryland
based psychiatric hospital within the past 3
months?
Yes
No
Advocate Support Services, Inc.
PRP_Referral_Form_6-22-09
Has the Consumer applied for Medical
Assistance and/or Social Security benefits?
Yes
1783 Forest Drive, #251 Annapolis, MD 21401
Is the Consumer currently enrolled in a day
program, or receive PRP services from another
provider?
Yes
No
Unknown
Is the Consumer currently receiving Mental Health
Case Management Services?
Yes
No
Unknown
Is the Consumer currently receiving Mobile
Treatment services?
Yes
No
Unknown
Does the Consumer currently attend an Adult
Medical Day Care?
Yes
No
Unknown
T 866-277-2080 F 800-372-0799
www.AdvocateSupport.com
Page 6 of 7
PRP REFERRAL FORM
Drugs & Alcohol
Please describe any current or history of Consumer Substance Abuse or Addiction. Please include any known
treatment and current status.
Services Needed
Please select one or more of the services below which you believe the Consumer would benefit from.
SELF CARE SKILLS: Consumer needs assistance, education &/or guidance with Self Care
Skills such as; community integration, developing natural supports, family relationships,
friendship/social relations, community participation, etc.
SOCIAL SKILLS: Consumer needs assistance, education &/or guidance with community
integration, developing natural supports, family relationships, friendship/social relations,
community participation, etc.
INDEPENDENT LIVING SKILLS: Consumer needs assistance, education &/or guidance with
Independent Living Skills such as; secure/maintain living environment, community awareness,
mobility skills, money management, entitlements, legal, etc.
CULTURAL: Consumer needs assistance, education &/or guidance with Cultural issues such as;
school, work, leisure interests, etc.
MEDICATION: Consumer needs assistance, education &/or guidance with Medications such as;
monitoring, prompting, education, symptom management, etc.
HEALTH PROMOTION & TRAINING: Consumer needs assistance, education &/or guidance
with Health Promotion & Training such as; nutrition, exercise, dental care, vision, substance
abuse prevention, prevention of injury, physical health management, etc.
HOUSING: Consumer needs assistance, education &/or guidance with Housing such as; needs
assessment, housing development, accessing subsidized rental support applications, accessing
utility assistance/management, accessing/maintaining housing, accessing emergency shelter/
housing, etc.
Presenting Problems, Current Symptoms & Additional Information
Briefly describe Consumer's current problems, symptoms and needs for community support. Include any
information that you feel will assist in determining eligibility and admission into Advocate's PRP.
Signature of person making this referral
Advocate Support Services, Inc.
PRP_Referral_Form_6-22-09
1783 Forest Drive, #251 Annapolis, MD 21401
T 866-277-2080 F 800-372-0799
Date
www.AdvocateSupport.com
Page 7 of 7