ALTA Healthcare Services
Adult Psychiatric Rehabilitation Program (PRP)

REFERRAL FORM

IDENTIFYING INFORMATION
Male
Female
Yes
No
Parent
Guardian
Foster Care Provider
Yes
No
DSM V DIAGNOSES
DSM diagnoses codes (scroll to the bottom)
  • None
    Educational
    Financial
    Access to Health Care
  • Legal System/Crime
    Primary Support
    Housing
    Occupational
  • Social Environment
    Homelessness
    Other Psychosocial & Environmental
    Unknown
Functional Assessment
Yes
No
Marked inability to establish or maintain independent competitive employment
Marked inability to perform instrumental activities of daily living
Marked inability to establish or maintain a personal support system
Marked or frequent deficiencies of concentration, persistence or pace
Marked inability to perform or maintain self-care
Marked deficiencies in self-direction
Marked inability to procure financial assistance
Yes
No
REASON FOR REFERRAL (Indicate the areas you want the PRP to address)
Personal hygiene/grooming
Nutrition/dietary planning
Dressing yourself
Following routines (bed, school, etc.)
Using the toilet
Self-administration of medication
Taking care of belongings
Maintaining living area
Safety skills
Mobility skills
Accessing entitlements
Money management
Interactive skills with peers
Interactive skills with family
Interactive skills with adults
Community integration
Participation in activities
Developing natural support
LICENSED MENTAL HEALTH PROFESSIONAL PROVIDING REFERRAL
Outpatient Mental Health
Inpatient Mental Health
Residential Treatment Center