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410.630.9064
Menu
About Us
Our Story
Our Staff
Careers
Services
Child Services
Adult Services
Clients
Client Portal
Pay Your Bill
PRP REFERRALS
Contact
Get Started
PRP Referral Form
To Be Completed by Referring Therapist
"
*
" indicates required fields
Empowerment Therapy Services of Maryland LLC
3655A Old Court Rd,Suite 1, Baltimore, MD ,21208
PRP Referral Form
Date
First Name
*
Last Name
*
Date of Birth
Sex
M
F
Race
Address
City
State
Zip
Phone Number
*
Email
MA#
Insurance Company
Marital Status
M
S
D
Minor Parent/Guardian Name
Phone Number (if different than above)
Emergency Contact
Relationship
School name (if applicable)
PRP eligibility is restricted to the following ICD-10 diagnoses for Adults (Minors can have any diagnosis). Please check all qualifying diagnoses:
Type
*
Adult
Minor
Adult Options
*
F20.9: Schizophrenia
F20.81: Schizophreniform Disorder
F25.0: Schizoaffective Disorder, Bipolar Type
F25.1: Schizoaffective Disorder, Depressive Type
F28:Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
F29:Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
F22:Delusional Disorder
F33.2:Major Depressive Disorder, Recurrent Episode, Severe
F33.3:Major Depressive Disorder, Recurrent Episode, With Psychotic Features
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
F31.9:Bipolar I Disorder, Current or Most Recent Episode Hypomanic, Unspecified
F31.9:Bipolar I Disorder, Current or Most recent episode, Unspecified
F31.9: Unspecified Bipolar and Related Disorder
F31.81: Bipolar II Disorder
F21:Schizotypal Personality Disorder
F60.3: Borderline Personality Disorder
Please Specify Diagnosis
*
Reason for PRP Referral (Clinical, please identify specifics):
Self Care/Social Skills
Grooming
Personal Hygiene
Nutrition
Food Preparation
Medication
Physical Health
Exercise
Recovery
Wellness
Communication
Peer Support
Family
Community Resources
Activities & Leisure
Other
Reason for PRP Referral
Self-care
Hygiene
Grooming
Nutrition/Food Preparation
Community Awareness and Safety
Family
Peer and Social
Academic/Vocational
Medical/Medication Management
Anxiety Symptoms
Executive Functioning Challenges
Social Skills Challenges
Mood Swings
Crying Fits
Anger Outbursts
Hallucinations
Self Isolation
Grieving
Focus Problems
Concentration Issues
Emotion Dysregulation
Other
Other Social Skills we should know about :
Independent Living Skills
Home Maintenance
Finances
Transportation
Entitlement
Community
Awareness & Safety
Employment
Adult Education
Shopping
Other
Other Living Skills
Signs and Symptoms
Mood Swings
Crying Fits
Anger Outbursts
Hallucinations
Fight or Flight
Self Isolation
Grieving
Personality Shift
Focus Problems
Concentration Issues
Other
Other Signs
Affecting the youth in the following settings
Home
School
Community
Affecting the youth in the following relationships
Peer Relationships
Family Relationships
Client Goals (Short-Term & Long-Term):
Agency Name and Address
State
City
Zip
Therapist Printed Name
*
Therapist Credentials
*
Therapist Phone Number
*
Therapist Email
*
Email
This field is for validation purposes and should be left unchanged.
