HOHTS REFERRAL FORM PRP

Your Email Address *

Initial *

Date *

Person-Served Name *

Demographic Information: (Please complete all sections in their entirety.) Must be signed and dated.

DOB *

SS#

Age *

Race *

Gender *

Highest grade completed *

Street Address *

City *

State *

Zip Code *

Home Phone *

Cell/Work *

Email *

Physical Description: *

Emergency Contact (Relationship to Person-Served) *

Contact’s Phone# *

(Work/Mobile) *

Please fill all the fields

Collaboration Agreement: (Please sign and date)

Clinician/Dr Name and Cred) *

refer

(Person-served name) *

and agree to collaborate with the PRP staff regarding the client’s rehabilitation treatment, including a re-referral request.
scheduled treatment sessions, and emergency team treatment planning sessions for the referred person-served.

Clinician’s Printed Name w/Credentials: *

Clinician’s Signature *

Clear

w/Credentials *

Agency Name *

Address *

City *

State *

Zip Code *

Agency Phone # *

Fax #

Referral must be signed by an independently licensed mental health professional, physician, or psychiatric nurse practitioner (LCPC, LCSW-C, MD (Psychiatrist), Psychologist, or CRNP-PMH).
All LG’s, PA and PA-C must have a supervisor's signature provided on referral as well.

Ready for submission

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HOHTS REFERRAL FORM PRP

Demographic Information: (Please complete all sections in their entirety.) Must be signed and dated.

Type of living situation

Data Standard for Primary Language

Do you speak a language other than English at home?

Insurance

PRP CRITERIA FOR ADULTS: Attach a copy of Psychosocial Assessment to the referral. (If available)
DSM and ICD10 diagnosis codes: The Individual must meet one of the following targets diagnostic codes to qualify for PRP services

Social Elements Impacting Diagnosis: (check all that apply)

Collaboration Agreement: (Please sign and date)

Referral must be signed by an independently licensed mental health professional, physician, or psychiatric nurse practitioner (LCPC, LCSW-C, MD (Psychiatrist), Psychologist, or CRNP-PMH).
All LG’s, PA and PA-C must have a supervisor's signature provided on referral as well.

HOHTS REFERRAL FORM PRP

Demographic Information: (Please complete all sections in their entirety.) Must be signed and dated.

Type of living situation

Data Standard for Primary Language

Do you speak a language other than English at home?

Insurance

PRP CRITERIA FOR ADULTS: Attach a copy of Psychosocial Assessment to the referral. (If available)DSM and ICD10 diagnosis codes: The Individual must meet one of the following targets diagnostic codes to qualify for PRP services

Social Elements Impacting Diagnosis: (check all that apply)

Collaboration Agreement: (Please sign and date)

Referral must be signed by an independently licensed mental health professional, physician, or psychiatric nurse practitioner (LCPC, LCSW-C, MD (Psychiatrist), Psychologist, or CRNP-PMH). All LG’s, PA and PA-C must have a supervisor's signature provided on referral as well.

PRP CRITERIA FOR ADULTS: Attach a copy of Psychosocial Assessment to the referral. (If available)
DSM and ICD10 diagnosis codes: The Individual must meet one of the following targets diagnostic codes to qualify for PRP services

Referral must be signed by an independently licensed mental health professional, physician, or psychiatric nurse practitioner (LCPC, LCSW-C, MD (Psychiatrist), Psychologist, or CRNP-PMH).
All LG’s, PA and PA-C must have a supervisor's signature provided on referral as well.