Other Information

    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.

    Referral Source: Must be referred by 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. 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.

    Clinical Information: (needed to request authorization for services)

    Required - Most Recent:

    Also, if available:


    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).

    ** 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**.

    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:

    Marked inability to establish or maintain independent competitive employmentMarked inability to perform instrumental activities of daily livingMarked inability to establish or maintain a personal support systemMarked or frequent deficiencies of concentration, persistence or paceMarked inability to perform or maintain self-careMarked deficiencies in self-directionMarked inability to procure financial assistance to support community living

    **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

    Please list other diagnoses, if applicable:

    Mental Health Diagnosis:

    Substance Use Information:

    Psychiatric Hospitalizations:

    Legal Information:

    Probation/Parole Officer:

    Community Forensic Aftercare Program: For applicants that have been adjudicated by the Circuit Court
    as Not Criminally Responsible:

    CFAP Monitor:

    Risk Assessment Information: If there is a history, please provide specific details


    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.