Adult Referral Form

Please complete information requested below. A member of our staff will contact you once information is reviewed.

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Referral Type

Initial

Concurrent

Name

First Last

Date(Required)

MM slash DD slash YYYY

DOB(Required)

MM slash DD slash YYYY

Sex

Race

Address

Street Address City State Zip

Marital Status

Education

Veteran

Yes

Recent Arrest?

Yes

Minor Parent/Guardian Name

Relationship

Emergency Contact

Phone

Emergency Contact Address

Street Address City State ZIP Code

PRP eligibility is restricted to the following ICD-10 diagnoses for Adults (Minors can have any diagnosis). Please check all qualifying diagnoses.

ICD-10 diagnoses for Adults

F20.0: Paranoid Schizophrenia

F20.1: Disorganized Schizophrenia

F20.2: Catatonic Schizophrenia

F20.3 Undifferentiated Schizophrenia

F20.5 Residual schizophrenia

F20.81: Schizophreniform Disorder

F20.89: Other Schizophrenia

F20.9: Schizophrenia

F22 Delusional Disorders

F25.0: Schizoaffective Disorder, Bipolar Type

F25.1: Schizoaffective Disorder, Depressive Type

F25.8: Other Schizoaffective Disorders

F25.9 Schizoaffective Disorder, unspecified

F28: Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

F31.0: Bipolar I Disorder, Current or Most Recent Episode Hypomanic

F31.13: Bipolar I Disorder, Current or Most Recent Episode Manic, Severe

F31.2: Bipolar I Disorder, Current or Most Recent Episode Manic, With Psychotic Features

F31.4: Bipolar I Disorder, Current or Most Recent Episode Depressed, Severe

F31.5: Bipolar I Disorder, Current or Most Recent Episode Depressed, With Psychotic Features

F31.63 Bipolar I Disorder, Mixed, Severe, Without Psychotic Features

F31.64 Bipolar I Disorder, Mixed, Severe With Psychotic Features

F31.81: Bipolar II Disorder

F31.9: Bipolar I Disorder, Unspecified

F33.2: Major Depressive Disorder, Recurrent Episode, Severe

F33.3: Major Depressive Disorder, Recurrent Episode, With Psychotic Features

F60.3: Borderline Personality Disorder

Other (for Minors only):

Reason for PRP Referral (Clinical, please identify specifics):

Reason for PRP Referral

Anxiety

Hyperactivity

Fatigue

Hopelessness

General Discontent

Disorganized Behavior

Irritability

Crying Fits

Fight or Flight

Personality Shift

Impulsivity

Paranoia

Guilt

Manic Episode

Elevated Mood

Restlessness

Excessive Sleepiness

Anger Outbursts

Self-Isolation

Focus Problems

Unwanted Thoughts

Agitated Depression

Agitation

Delusion

Suicidal Ideation

Slowness in Activity

Mood Swings

Hallucinations

Grieving

Concentration Issues

Other PRP Referral

History of Presenting Problem

Medication List

Please identify client concerns or services. Check all that apply.

client concerns or services

Daily Living Activities

Anger/Temper/Conflict Resolution

Assertiveness /Self-Esteem

Community Activity

Family/Natural Supports

Finances

Home/Housing

Self-Care Skills

Safety Concerns for Self or Others

School Performance

Sexual Issues

Social Skills/Peer Interaction

Substance Abuse Issues

Coping Skills

Trauma

Medication Compliance Skills

Vocation Skills

Leisure Skills

Work/Job Performance

Legal Issues (# of arrests)

Financial Management

Dietary/Food Preparation

Crisis Management

Physical Health

Other concerns or services

Printed Name & Credentials

Medical Practitioner/Therapist Name

Adult Functional Criteria & Needs

Name

1. Are you employed?

Yes

a. Do you wish to be employed?

Yes

b. What was your last employment and why are you no longer employed with them?

c. Is there anything that is holding you back from establishing and maintaining competitive employment?

d. Are you able to financially support yourself?

Yes

e. Are you able to financially support yourself and your family

Yes

2. Are you able to complete your daily needs consistently and on the regular? (ex: basic housekeeping, meal preparation, laundry, shopping, money management, etc)

Yes

a. If not, what’s preventing you from doing it?

b. Can you give me an example of when you weren’t able to complete your daily needs?

3. What is your relationship status:

Single

Married

Divorced

a. How is your relationship?

4. Do you have a family or friends? Do you have children?

Yes

a. Do they support you when you need them?

Yes

b. What type of relationship do you have with them and how is your relationship with them? Describe it to me please.

5. Does your mental health or substance abuse affect your functioning or the way you live your life?

Yes

a. How does your mental health or substance abuse affect your life or prevent you functioning appropriately or live your life the way that you want to?

b. Give me an example of when your mental health or substance abuse had a negative impact in your life?

6. Are you able to take care of yourself with self-care and hygiene or grooming? Or medical needs?

Yes

7. Are you goal oriented?

Yes

a. What are your goals and ambitions?

b. What has prevented you from reaching your goals?

What is the color of our Flag?(Required)

Elevated Wellness Clinic

At Elevated Wellness Clinic in Maryland, we understand the journey to mental wellness is deeply personal. Our Elevated Wellness Clinic facility is designed to provide a serene, supportive environment, where every individual can find the path to their best self. Contact us to discover how we can help you or your loved ones on this journey to mental wellness.

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