REFERRAL for ADULT PSYCHIATRIC REHABILITATION PROGRAM (PRP) SERVICES (Community-Based Support Services)

Name

First Name Middle Name Last Name

Telephone

Home Cell Other

Address

Street City State Zip

Other Information

DOB Age SSN# Veteran —Please choose an option—YesNo Gender Identity —Please choose an option—MaleFemaleMale-to-Female (MTF)/Transgender Female/Trans WomanFemale-to-Male (FTM)/Transgender Male/Trans ManGenderqueer, Neither Exclusively Male or FemaleAdditional Gender Category or Other (please specify)Choose Not to Disclose If, Additional Gender Category or Other, please specify: Do you have a relative that is currently employed by Archway Station, Inc.: —Please choose an option—YesNo If yes, please provide person’s name:

Please provide the name and telephone number of a person we can contact in the event that there is difficulty reaching the person being referred for services.

Name Telephone # Relationship Medical Assistance #: MCO (if known):

If the person does not have Medicaid, Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Medicare Beneficiary (QMB) eligibility, they must meet one of the four exception criteria to be eligible for state-funded services:

On conditional release from state hospital. Discharged from inpatient psychiatric hospitalization within the last 6 months. Date of Discharge:
Released from jail within the last 6 months. Date of Release:
Discharged from a RRP within the last 6 months. Date of Discharge:

Referral Source:

The referring person must be a Licensed Mental Health Professional. A “Licensed Mental Health Professional” eligible to make referrals to a PRP is defined as a Psychiatrist, CRNP-PMH, Licensed Psychologist, LCSW-C, LCPC, APRN-PMH, LCMFT, LCADC, LCPAT, LGMFT, LGADC or LGPAT. Note: LGPC, LGMFT, LGADC, LGPAT and LMSW staff may only make referrals if they are currently in a formal clinical supervision arrangement with a supervisor approved by the Maryland Board of Professional Counselors and Therapists or the Maryland Board of Social Work Examiners, as applicable. (Supervisor’s name, title and location must be provided). Referrals from non-mental health professionals who do not have a mental health specialty are not permitted. RN-C, CAC-AD and CSC-AD are not eligible to make referrals. The Licensed Mental Health Professional must be actively enrolled as a Medicaid provider.

Type of Provider: InpatientResidential CrisisMobile/Assertive Community TreatmentMental Health RTCIncarcerationOutpatient Mental Health Provider Name License/Credentials Telephone # Email (by providing your email address you will receive a copy of this referral) Agency NPI # Supervisor’s Name (if applicable) Supervisor’s License/Credentials Supervisor’s Telephone # Supervisor’s Agency NPI #

Outpatient Mental Health Provider

Same as Referral SourceOther Below Why is ongoing outpatient treatment not sufficient to address concerns?

Other Levels of Care:

• Have any of the following been considered or attempted:
  • 1. Peer supports and/or informal supports such as family: —Please choose an option—YesNo
  • 2. Group therapy: —Please choose an option—YesNo
  • 3. Target Case Management?: —Please choose an option—YesNo

If the answer to any of these questions is yes, explain why this has not been successful: If the answer to any of these questions is no, explain why they have not been tried PRP may not routinely be provided in conjunction with the following: Mobile Treatment/Assertive Community Treatment; Targeted Case Management; IOP (Substance/Mental Health). If the person is receiving one of these services, please provide clinical rationale as to why both services are needed along with a transition plan.

Diagnosis:

The individual must meet the DSM-5 diagnostic criteria for a Public Behavioral Health System (PBHS) specialty mental health diagnosis in the Priority Population (either Category A or Category B).

Category A Diagnoses: —Please choose an option—Does Not have a Category A DiagnosisF20.0 Paranoid SchizophreniaF20.1 Disorganized SchizophreniaF20.2 Catatonic SchizophreniaF20.3 Undifferentiated SchizophreniaF20.5 Residual SchizophreniaF20.81 Schizophreniform DisorderF20.89 Other SchizophreniaF20.9 Schizophrenia, UnspecifiedF22 Delusional DisordersF25.0 Schizoaffective Disorder, Bipolar TypeF25.1 Schizoaffective Disorder, Depressive TypeF25.8 Other Schizoaffective DisordersF25.9 Schizoaffective Disorder, UnspecifiedF28 Other Specified Schizophrenia Spectrum and Other Psychotic DisorderF29 Unspecified Schizophrenia Spectrum and Other Psychotic DisorderF31.2 Bipolar / Disorder, Current or Most Recent Episode Manic, with Psychotic FeaturesF31.5 Bipolar / Disorder, Most Recent Episode Depressed, with Psychotic FeaturesF31.64 Bipolar / Disorder, Mixed, Severe with Psychotic FeaturesF33.3 Major Depressive Disorder, Recurrent Episode Severe, with Psychotic Features

OR

Category B Diagnoses: —Please choose an option—Does Not have a Category B DiagnosisF31.0 Bipolar I Disorder, Current or Most Recent Episode HypomanicF31.13 Bipolar I Disorder, Current or Most Recent Episode Manic, SevereF31.4 Bipolar I Disorder, Current or Most Recent Episode Depressed, SevereF31.63 Bipolar I Disorder, Mixed, Severe without Psychotic FeaturesF31.81 Bipolar II DisorderF31.9 Bipolar I Disorder, UnspecifiedF33.2 Major Depressive Disorder, Recurrent Episode, Severe without Psychotic FeaturesF60.3 Borderline Personality Disorder

The specific diagnostic criteria may be waived for one of the following two conditions:

An individual committed as not criminally responsible who is conditionally released from a Mental Hygiene Administration facility, according to the provisions of Health General Article, Title 12, Annotated Code of Maryland.An individual in a Mental Hygiene Administration facility with a length of stay of more than 6 months who requires RRP services, but who does not have a target diagnosis. This excludes individuals eligible for Developmental Disabilities services.

For Category A Diagnoses, either of the following may be met. For Category B Diagnoses, the individual being referred must demonstrate three of the listed role functioning impairments for at least two years**.

**Individuals meeting the role functioning impairment criteria who do not yet have two years of impaired functioning may be considered for psychiatric rehabilitation services if they have a new onset Category A Diagnosis and psychiatric rehabilitation services would be considered the most effective means to diminish the risk.Please check here, if applicable

The individual is currently enrolled in SSI or SSDIThe individual demonstrates impaired role functioning for at least two years. To be considered evidence of impaired role functioning, at least three of the following must have been present on a continuing or intermittent basis (please check all that apply). For each one selected you are required to answer the associated questions.

• Marked inability to establish or maintain independent competitive employment
  • 1. Describe the symptoms of the Priority Population Diagnosis that affect the person’s functioning:
  • 2. Describe how specifically these symptoms impair the person’s functioning:
  • 3. Provide specific concrete examples of this person’s impaired function:
• Marked inability to perform instrumental activities of daily living
  • 1. Describe the symptoms of the Priority Population Diagnosis that affect the person’s functioning:
  • 2. Describe how specifically these symptoms impair the person’s functioning:
  • 3. Provide specific concrete examples of this person’s impaired function:
• Marked inability to establish or maintain a personal support system
  • 1. Describe the symptoms of the Priority Population Diagnosis that affect the person’s functioning:
  • 2. Describe how specifically these symptoms impair the person’s functioning:
  • 3. Provide specific concrete examples of this person’s impaired function:
• Marked or frequent deficiencies of concentration, persistence or pace
  • 1. Describe the symptoms of the Priority Population Diagnosis that affect the person’s functioning:
  • 2. Describe how specifically these symptoms impair the person’s functioning:
  • 3. Provide specific concrete examples of this person’s impaired function:
• Marked inability to perform or maintain self-care
  • 1. Describe the symptoms of the Priority Population Diagnosis that affect the person’s functioning:
  • 2. Describe how specifically these symptoms impair the person’s functioning:
  • 3. Provide specific concrete examples of this person’s impaired function:
• Marked deficiencies in self-direction
  • 1. Describe the symptoms of the Priority Population Diagnosis that affect the person’s functioning:
  • 2. Describe how specifically these symptoms impair the person’s functioning:
  • 3. Provide specific concrete examples of this person’s impaired function:
• Marked inability to procure financial assistance to support community living
  • 1. Describe the symptoms of the Priority Population Diagnosis that affect the person’s functioning:
  • 2. Describe how specifically these symptoms impair the person’s functioning:
  • 3. Provide specific concrete examples of this person’s impaired function:

Medications

Medications Prescribed: —Please choose an option—Yes, List AttachedYes, Written BelowNo Medications Prescribed

If Primary Diagnosis is a mood disorder, it is mandatory to list all medications used to treat this disorder. Please specify which medications are being used for this purpose.

* If no medications are prescribed, please provide explanation as to why medications are not being used.

Ability to take Medications: —Please choose an option—IndependentlyWith RemindersWith Daily SupervisionRefuses MedicationsMedications Not Prescribed

Substance Use:

Substance Use History (Include details of substance used, including alcohol, dates used, frequency, and amount.) Treatment History for Substance Use Disorders (Include details of treatment history, including detox, inpatient & outpatient services as well as dates of treatment)

Psychiatric Hospitalizations:

Summarize Below (include hospital name & dates):

Legal Information:

Currently on Probation/Parole: —Please choose an option—YesNo If yes, probation end date:

Probation/Parole Officer:

Currently on a Conditional Release Order from the Court/Judge: —Please choose an option—YesNo If yes, conditional release order expiration date: Has applicant ever been found NCR (Not Criminally Responsible)?: —Please choose an option—YesNo Is applicant required to register through the MD Sex Offender Registry: —Please choose an option—YesNo If yes, specify the level as identified by the MD Sex Offender Registry: —Please choose an option—Tier1Tier2Tier3 Please provide any details relating to the person's legal situation that you feel we should be aware of:

Risk Assessment:

Does the person have a current presentation or history of the following: If yes, please provide additional information.

Suicide Attempts: —Please choose an option—NeverPast Week-MonthPast Month-YearPast 2+ Years Suicide Ideations: —Please choose an option—NeverPast Week-MonthPast Month-YearPast 2+ Years Aggressive Behavior/Violence: —Please choose an option—NeverPast Week-MonthPast Month-YearPast 2+ Years Fire Setting/Arson: —Please choose an option—NeverPast Week-MonthPast Month-YearPast 2+ Years Sexual Behavior(s) that are/were non-consensual, injuries, high-risk, forcible, pedophilia, etc.: —Please choose an option—NeverPast Week-MonthPast Month-YearPast 2+ Years Self-Injuries/Mutilation (not suicidal): —Please choose an option—NeverPast Week-MonthPast Month-YearPast 2+ Years

Reason for Referral:

Please provide details reason you are recommending this person for PRP services:

Clinical Documentation

The following clinical documentation is required and must be submitted along with this completed referral:

• Most recent Psychiatric/Psychosocial Evaluation
• Individual Treatment Plan
• Progress/Med Notes (2 to 3 months of recent notes)

If there is any other evaluations/information that you feel helps describe the person's need for services, please include that as well.

Signatures

I understand that this application is being sent in order to determine if I am eligible to obtain rehabilitation services from Archway Station, Inc. This application does not bind me to receive services. I still have the right to change my mind later. I give Archway Station, Inc. permission to communicate with the referral source to discuss and share medical and mental health history and information necessary for my referral.

I recommend that this person receive rehabilitation services from Archway Station, Inc. (Must be referred by a Licensed Mental Health Professional. Please see the eligible list of eligible referral sources on page 1 of this referral.)

If not submitted electronically, completed referrals, along with all required attachments, can be submitted via fax or mail. Please send to the attention of ‘Intake Coordinator’. Fax to (301) 777-8020 or Mail to Archway Station, Inc., 45 Queen St., Cumberland, MD 21502.