ALTA Healthcare Services
Minor & Adolescent Psychiatric Rehabilitation Program (PRP)
101 Lakeforest Blvd #250, Gaithersburg, MD 20877

REFERRAL FORM

IDENTIFYING INFORMATION
Male
Female
Yes
No
Parent
Guardian
Foster Care Provider
Yes
No
DSM V DIAGNOSES
(A MINOR MUST HAVE A BEHAVIORAL DIAGNOSIS AND BE REFERRED BY A LICENSED MH PROFESSIONAL TO BE ELIGIBLE FOR PRP.)
  • None
    Educational
    Financial
    Access to Health Care
    Legal System/Crime
    Primary Support
  • Housing
    Occupational
    Social Environment
    Homelessness
    Other Psychosocial & Environmental Element
    Unknown
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
Money management
Mobility skills
Accessing entitlements
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

Send the form Professional Assertion of Need for PRP Services and a copy of your current Treatment Plan to info@altahcs.com