Minor Referral Form

Psychiatric Rehabilitation Program and
Mental Health Support Services

Home
About us
- Goals and Objectives
- Testimonials
Services
Session Calendar
- Meeting Participation Form
Referral Form
Employment
Contact
More

Use tab to navigate through the menu items.

Referral Date

Client's First Name

Address

Initial

Concurrent

Client's Last Name

Cell number

Marital Status

Age

Date of Birth

Home number

Veteran?

Social Security Number

Race

Ethnicity

Gender

Insurance Type

Guardian's First Name

Guardian's Address

MCO

Guardian's Last Name

Guardian's Phone Number

Medicaid Number

Relationship

Guardian's Email

ICD 10 PRIMARY DIAGNOSIS GIVEN:

ADDT’L DIAGNOSIS GIVEN:

Length of Time in Therapy

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

Entitlements

Educational Support

Leisure Skills

Health Support

Independent Living

Employment Support

Housing Support

Social and Community

Selfcare

Transportation

What are the social elements impacting diagnosis?

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

FUNCTIONAL CRITERIA

Functional Impairments: (Individual MUST meet a minimum of 2 criteria below relating to their diagnosis).
All responses need to be detailed.

1. Is there a clear, current threat to the youth’s ability to be maintained in their customary setting?

3. List any significant psychological impairments causing serious problems with peer and/or family relationships as it relates to the youth’s mental health:

Medication/Dosage/Prescribing Physician

2. Is the youth at an emerging risk to the safety of themselves or others?

4. Does the youth 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 the youth’s mental health?

Additional Needs of Concerns

REFERRAL INFORMATION/REFERRAL SOURCE:

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

Referring Clinician

Clinician Email

Clinician Phone

Credentials

Select a date

Supervisor Name

Supervisor credentials

Supervisor's Email

Supervisor's Contact Number

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

Thanks for submitting!

Psychiatric Rehabilitation Program and Mental Health Support Services