School-Based Services Referral Form Please fill out the form to apply. NameThis field is for validation purposes and should be left unchanged.Client / Referral InformationName(Required) First Last Phone(Required)Today's Date(Required) Date of Birth(Required) Is this PRP referral for a Minor (under 18 years old) or an Adult?(Required) Minor Adult Gender Male Female RaceMA#(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code School Attending(Required)Current/ Highest Grade Completed(Required)Marital Status(Required)Resides with(Required)Parent/Guardian Name(Required) First Last Relationship(Required)Do the Parent/ Guardian have legal custody of the student?(Required) Yes No Legal Guardian Name(Required) First Last Legal Guardian Phone(Required)Legal Guardian Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code **Please Note: Services cannot begin unless proof of custody is provided**Does the client have an IEP?(Required) Yes No If Yes, Level of Special Education(Required)PCP & Location(Required)PCP Phone(Required)Referring Clinician(Required)Clinical Supervisor (if referring Clinician is a LMSW or LGPC)Reason for Referral(Required)Client Strengths(Required)Substance Abuse?(Required) Yes No If Yes, Please Explain Substance Abuse(Required)Legal Involvement?(Required) Yes No If Yes, Please Explain Legal Involvement(Required)Previous / Current Suicidal Ideation(Required) Yes No If Yes, Please Explain Suicidal Ideation(Required)Past Psychiatric Admission(s)(Required) Yes No Previous Outpatient Treatment(Required) Yes No Current Outpatient ProviderCurrent Outpatient Provider PhonePrimary Behavioral Dx(Required)Primary Medical DxPlease check off the following rehabilitation and support services that the MINOR may need:(Required) Age Appropriate self care skills, including: A) Personal Hygiene B) Grooming C) Nutrition D) Dietary Planning Food Preparation Self administration of medication Social Skills - developing natural supports and developing linkages with supporting minor's participating in community activities Conflict Resolution Anger Management Maintaining Personal Living Space Maintaining Age-appropriate boundaries Activities that support consumer's cultural interests Maintaining personal safety in social environment Time management including use of structured and unstructured time Independent Living Skills including: A) Mobility skills B) Money Management C) Maintenance of the consumer's living environment D) Community awareness Interactive skills with peers and authority figures Promotion of Illness Self-Management Providing education and information regarding mental illness Identifying effecting strategies to assist the consumer to manage the consumer's illness Potential problematic symptoms Warning signs of relapse, helpful interventions and utilizing other individuals to resolve the situation in order for the consumer to remain in service or to seek treatment. Accessing available entitlements and resources This field is hidden when viewing the formPlease check off the following rehabilitation and support services that the MINOR may need: Age Appropriate self-care skills, including A) Personal Hygiene B) Grooming C) Nutrition D) Dietary Planning Food Preparation Self-Administration of Medication Social Skills – Developing natural supports and developing linkages with supporting minor’s participating in community activities Conflict Resolution Anger Management Maintaining Personal Living Space Maintaining Age Appropriate boundaries Activities that support consumer’s cultural interests Maintaining personal safety in social environment Time management including use of structured and unstructured time Independent Living Skills including A) Mobility skills B) Money Management C) Maintenance of the consumer's living environment D) Community awareness Interactive skills with peers and authority figures Promotion of Illness Self-Management includes A) Providing education and information regarding mental illness B) Identifying effecting strategies to assist the consumer to manage the consumer's illness C) Potential problematic symptoms D) Warning signs of relapse, helpful interventions and utilizing other individuals to resolve the situation in order for the consumer to remain in service or to seek treatment. Accessing available entitlements and resources Supporting the individual to obtain and retain employment Skills necessary for housing stability Please check off the following rehabilitation and support services that the ADULT may need:(Required) Age Appropriate self care skills, including: A) Personal Hygiene B) Grooming C) Nutrition D) Dietary Planning Food Preparation Self administration of medication Social Skills - developing natural supports and developing linkages with supporting minor's participating in community activities Activities that support consumer's cultural interests Independent Living Skills including: A) Mobility skills B) Money Management C) Maintenance of the consumer's living environment D) Community awareness Promotion of Illness Self-Management Providing education and information regarding mental illness Identifying effecting strategies to assist the consumer to manage the consumer's illness Potential problematic symptoms Warning signs of relapse, helpful interventions and utilizing other individuals to resolve the situation in order for the consumer to remain in service or to seek treatment. Accessing available entitlements and resources Supporting the individual to obtain and retain employment Skills necessary for housing stability This field is hidden when viewing the formPlease check off the following rehabilitation and support services that the ADULT may need: Age Appropriate self-care skills, including A) Personal Hygiene B) Grooming C) Nutrition D) Dietary Planning Food Preparation Self-Administration of Medication Social Skills – Developing natural supports and developing linkages with supporting consumer's participating in community activities Activities that support consumer’s cultural interests Independent Living Skills including A) Mobility skills and transportation skills B) Money Management C) Maintenance of the consumer's living environment D) Community awareness Promotion of Illness Self-Management includes A) Providing education and information regarding mental illness B) Identifying effecting strategies to assist the consumer to manage the consumer's illness C) Potential problematic symptoms D) Warning signs of relapse, helpful interventions and utilizing other individuals to resolve the situation in order for the consumer to remain in service or to seek treatment. Accessing available entitlements and resources Supporting the individual to obtain and retain employment Skills necessary for housing stability Please explain how the Psychiatric Rehabilitation Program (PRP) can provide assistance with the above marked services and how PRP can help the consumer manage their disorder and to support recovery as it relates to their treatment goals.(Required)Case Management Needs(Required)Financial InformationEmployment StatusPayment SourceIncome Source***Please forward copies of latest physical, immunization records and custody papers (if legal guardian is not the biological parent). Please attach copy of initial clinical evaluation and latest clinical treatment plan.***
