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: Medical Assistance #: MCO (if known): 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 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: 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. 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 # Is the person being referred currently engaged in Outpatient Mental Health Treatment? —Please choose an option—YesNo If yes, who is their current provider? Clinical Information: (needed to request authorization for services) Required - Most Recent: Psychiatric/Psychosocial EvaluationIndividual Treatment PlanProgress Notes (2 to 3 months of recent notes) Also, if available: Discharge Plan (if person is leaving a hospital)Current Physical Exam ResultsAny other evaluations or information that help describe the person’s status/needs. 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 ** 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. 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 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: 1) ICD-10 Code 2) ICD-10 Code 3) ICD-10 Code Medical Diagnosis: Other Conditions that may be a Focus of Clinical Attention: Allergies: —Please choose an option—YesNo If yes, please describe: Presenting Problem: Medications Prescribed: —Please choose an option—Yes, List AttachedYes, Written BelowNo Medications Prescribed Ability to take Medications: —Please choose an option—IndependentlyWith RemindersWith Daily SupervisionRefuses MedicationsMedications Not Prescribed Substance Use Information: Substance Use History (Include details of substance used (including alcohol), dates used, frequency, amount and how used (smoked, IV, etc.) Treatment History for Substance Use Disorders (Include detox, inpatient & outpatient services as well as dates of treatment) Psychiatric Hospitalizations: Most Recent Psychiatric Admission: Total # of Psychiatric Admissions: Reason: 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: Name: Telephone #: 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 Community Forensic Aftercare Program: For applicants that have been adjudicated by the Circuit Court as Not Criminally Responsible: CFAP Monitor: Name: Telephone #: 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 Current Charges: Reported Convictions: Risk Assessment Information: If there is a history, please provide specific details 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 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. Name of Applicant Please check here to confirm your electronic signature: Date 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.) Name of Referral Source Please check here to confirm your electronic signature: Date Name of Supervisor (if applicable) Please check here to confirm your electronic signature: Date 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.