Supported Employment Referral Form

• Client Name: *
• Gender: * MaleFemale
• DOB: *
• Address: *
• City: *
• State: * —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Zip Code: *
• Medical Assistance #: *
• Cell Phone: *
• Home Phone: *
• Work Phone: *
• Client Email: *

• Referral Source Information

• Agency Name: *
• Phone: *
• Agency's Email: *
• Referring/Treating Clinician: *
• Fax: *
• Address: *
• City: *
• State: * —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Zip Code: *

• Employer/School

• School/Employer Name: *
• Grade: *
• Phone: *

• Reason for Referral/Presenting Problems

• Please provide a detailed description of client behaviors and all treatment presentations (including school concerns):
• Please provide details regarding behavioral history (including hospitalizations, out-of-home placement, previous mental health treatment, etc.):
• Check box if no previous hospitalizations or treatment history
• Frequency of treatment provided to this individual: * At least 1x/weekAt least 1x/monthAt least 1x/6 months
• How long has the individual been engaged in active outpatient treatment? * Less than one month2-3 months4-6 months7-12 monthsMore than 12 months

• Last Therapy Session

• ADULT CLIENTS ONLY: Has the individual received PRP services from at least one other PRP agency within the past year?
• Rehabilitation Services Needed: * Activities of Daily LivingAnger/Temper/Conflict ResolutionAssertiveness/Self-EsteemCommunity ActivityFamily/Natural SupportsFinancesHome/HousingSelf-Care SkillsSelf-Injurious BehaviorsSafety to Self/OthersSchool PerformanceSexual IssuesSocial Skills/Peer InteractionSubstance Abuse IssuesCoping SkillsConflict ResolutionTraumaMedication Compliance SkillsVocational SkillsLeisure SkillsWork/Job PerformanceLegal IssuesMoney ManagementDietary/Food PreparationCrisis Management SkillsPhysical Health
• Current Treatment(s) Goals (Please include current treatment goals and type of services received):

Diagnosis: If applicable, please indicate current DSM diagnoses

• Primary Behavioral Diagnosis:

• Diagnosis Code 1: *
• Description: *
• Diagnosis Code 2: *
• Description: *
• Diagnosis Code 3: *
• Description: *

• Primary Medical Diagnosis (please include all medical concerns):

• Diagnosis Code: *
• Description: *

• Socioeconomic/Psychosocial Assessment:

• Please check all that apply: NoneLimited Primary SupportHousing ProblemsSocial Environment ConcernsFinancial ProgramsAccess to HealthcareEducational ProblemsLegalUnknown
• Diagnosed/Referred By: (please include licensure) *

• Medications

• Type of Medication *
• Dosage *
• Frequency *
• Type of Medication *
• Dosage *
• Frequency *

• Custodial Care

• Name of Guardian: *
• Phone: *
• Address: *
• Foster Care Placement (if applicable):

• Collaborative Agreement

• I, (Therapist Name and Title) agree to participate in team treatment planning sessions/initial session within two weeks of receipt of the referral and quarterly sessions in person or by phone.
• ** Please upload all relevant medical records (clinic/hospital notes, test, lab or other imaging results, and pertinent consultations. Please include any necessary insurance referral authorizations.) Thank you.
• Upload Files: *

• Signature

• Signature: *
• Date *

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