PRP Referral Form

Client Information
Mobile
Home
Male
Female
Yes
No
PRP Program
  • None
    Educational
    Financial
  • Access to Health Care
    Access to Legal Services
    Primary Support
  • Housing Problems
    Occupational
    Homelessness
  • Social Environment
    Other Psychosocial Elements
    Unknown
Yes
No
Inability to maintain independent employment
Social behavior that results in interventions by the mental health system
Inability to procure financial assistance due to cognitive disorganization
Severe inability to establish or maintain social support
Need assistance with basic activities of daily and self-direction
Yes
No
Yes
No
REASON FOR REFERRAL
Personal hygiene
Grooming
Nutrition
Dietary planning
Food preparation
Self-administration of medication
Community integration activities
Maintaining living area
Developing natural support
Developing linkages with and supporting the individual’s participation in community activities
Skills necessary for housing stability
Community awareness
Mobility and transportation skills
Money management
Accessing available entitlements and resources
Supporting the individual to obtain and retain employment
Health promotion and training
Individual wellness, self-management and recovery
Priority Population Diagnoses – Adults

Please use the diagnoses listed below as the primary diagnosis(es) for the applicant

DSM-5 Diagnosis ICD-9 CODE ICD-10 CODE
CATEGORY A
Schizophrenia 295.90 F20.9
Schizophreniform Disorder 295.40 F20.81
Schizoaffective Disorder, Bipolar Type 295.70 F25.0
Schizoaffective Disorder, Depressive Type 295.70 F25.1
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder 298.8 F28
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder 298.9 F29
Major Depressive Disorder, Recurrent Episode, withPsychotic Features 296.34 F33.3
Bipolar I Disorder, Current or Most Recent Episode, Manic, withPsychotic Features 296.44 F31.2
Bipolar I Disorder, Current or Most Recent Episode, Depressed,with Psychotic Features 296.54 F31.5
Schizotypal Personality Disorder 301.22 F21
CATEGORY B
Major Depressive Disorder, Recurrent Episode, Severe 296.33 F33.2
Bipolar I Disorder, Current or Most Recent Episode, Manic 296.43 F31.13
Bipolar I Disorder, Current or Most Recent Episode, Depressed,Severe 296.53 F31.4
Bipolar I Disorder, Current or Most Recent Episode, Hypomanic 296.40 F31.0
Bipolar I Disorder, Current or Most Recent Episode, Hypomanic,Unspecified 296.40 F31.9
Bipolar I Disorder, Current or Most Recent Episode, Unspecified 296.7 F31.9
Unspecified Bipolar and Related Disorder 296.80 F31.9
Bipolar II Disorder 296.89 F31.81
Borderline Personality Disorder 301.83 F60.3
The diagnostic criteria may be waived for either one of the following two conditions:
1. An individual committed as not criminally responsible who is conditionally released from a Mental Hygiene facility, according to the provisions of Health General Article, Title 12, Annotated Code of Maryland. Please check if applicable:
2. An individual in a Mental Hygiene facility with a length of stay of more than 6 months who requires RRP services. This excludes individuals eligible for Developmental Disabilities services. Please check if applicable: