Adult Referral Form

Psychiatric Rehabilitation Program and
Mental Health Support Services

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Referral Date

Client's First Name

Address

Social Security Number

Insurance Type

Highest Level of Education

Is the client currently receiving SSI/SSDI?

Category B Diagnoses

What are the social elements impacting diagnosis?

Is there any history of suicidal ideations, suicidal attempts, psychiatric hospitalizations? List in details duration and frequencies:

Initial

Concurrent

Client's Last Name

Cell number

Marital Status

Age

Date of Birth

Home number

Veteran?

Race

Ethnicity

Gender

MCO

Employment Status

Medicaid Number

Length Time in Therapy

ICD 10 PRIMARY DIAGNOSIS GIVEN (please check the appropriate box):

Additional diagnosis given

Service Requested/Reason for referral (Check all tat apply)

Entitlements

Educational Support

Leasure Skills

Health

Independent Living

Employment Support

Housing Support

Social & Community

Self Care

Mobility

Other

Functional Impairments: (Individual MUST meet a minimum of 3 criteria below relating to their diagnosis).All responses need to be detailed.

1. List any marked inability to establish or maintain competitive employment as it relates to this individual’s diagnosis:

2. List any marked inability to perform daily living activities such as shopping, meal prep, laundry, basic housekeeping, medication management, transportation and/or money management.

3. List any marked inability to establish/maintain a personal support system as it relates to the individual’s mental health:

4. Does the individual have deficiencies of concentration as it relates to failing to complete tasks, inability to plan, carry out goal directed activities? How does it relate to this individual’s mental health?

5. List any evidence of this individual’s inability to procure financial assistance to support community living:

6. Has peer or family support been deemed viable to assist this individual in managing their mental health? List your reasons:

Medication/Dosage/Prescribing Physician

Additional needs/areas of concern:

REFERRAL INFORMATION/REFERRAL SOURCE:

(If LMSW, LGMFT or LGPC, please include your clinical supervisor’s name and credentials)

Printed Name of Referring Clinician

Email Address

Phone

Credentials

Select a date

Clinical Supervisor Name/Credentials

Clinical Supervisor E-mail Adress

Clinical Supervisor's Phone

Is the clinician or clinical supervisor enrolled in Medicaid?

Agency Name

By clicking here you verify the accuracy of the information provided on this form

Contact Information:

Address:
J & A Positive Image
9650 Santiago Road, Suite 11
Columbia, MD 21045
Phone number: 410-796-2039
(24 hours emergency services)

Fax: 410-796-1410

Email: info@japositiveimage.com

© 2024 J&A Positive Image - All rights reserved.
As a psychiatric rehabilitation program (PRP),
J & A Positive Image, LLC will help clients with priority mental health diagnoses work toward wellness and recovery.

For any questions/inquiries Contact us here

First Name

Last Name

Add questions/inquires here

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Psychiatric Rehabilitation Program and Mental Health Support Services