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ALTA Healthcare Services
Minor & Adolescent Psychiatric Rehabilitation Program (PRP)
101 Lakeforest Blvd #250, Gaithersburg, MD 20877
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Phone:
(240) 801-9818
Fax:
(240) 801-9819
Email:
info@altahcs.com
REFERRAL FORM
IDENTIFYING INFORMATION
Minor's Name:
*
Date of Birth:
*
Age:
*
Address:
*
Social Security #:
*
Sex:
*
Male
Female
City:
*
State:
*
Zip Code:
*
Medical Assistance #:
*
Phone:
*
Access to Transportation for On-Site Activities:
Yes
No
Relationship:
*
Parent
Guardian
Foster Care Provider
Adult Contact's Name:
*
Address (if different):
Phone Number:
*
Does the Person of Contact have legal custody?
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.)
Behavioral Diagnosis Code:
*
Diagnosis Code:
Description:
Diagnosis Code:
Description:
Diagnosis Code:
Description:
Primary Medical Diagnoses:
*
Description:
Social Elements Impacting Diagnoses:
*
None
Educational
Financial
Access to Health Care
Legal System/Crime
Primary Support
Housing
Occupational
Social Environment
Homelessness
Other Psychosocial & Environmental Element
Unknown
Source of Diagnosis:
*
Functional Assessment:
(if applicable)
Measures Used:
Score:
REASON FOR REFERRAL
(Indicate the areas you want the PRP to address)
Self Care Skills:
(Check all that apply)
Personal hygiene/Grooming
Nutrition/dietary planning
Dressing yourself
Following routines (bed, school, etc.)
Using the toilet
Self-administration of medication
Semi-Independent Living Skills:
(Check all that apply)
Taking care of belongings
Maintaining living area
Safety skills
Money management
Mobility skills
Accessing entitlements
Interactive Skills with Others:
(Check all that apply)
Interactive skills with peers
Interactive skills with family
Interactive skills with adults
Leisure/Social Skills:
(Check all that apply)
Community integration
Participation in activities
Developing natural support
Anger Management Skills:
Education:
Symptom Management:
Community/Family Resources:
Other:
LICENSED MENTAL HEALTH PROFESSIONAL PROVIDING REFERRAL
Name & Credentials:
*
Agency/Organization:
*
Street Address:
*
Phone Number:
*
City:
State:
Zip Code:
E-mail Address:
*
Signature:
*
Mental Health Treatment Currently Being Provided:
*
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