Referral

How to Apply For Our Services

Your mental health care provider will complete a referral form on your behalf and fax it to our office at 443-571-7611 or our phone on 443-990-3300. We also require your psychosocial information and evaluation to help us to serve you better. Please fill out the form below, to send in your referral. If the form below does not open, use the Online Referral Form button, to open the form in a separate window.

Online Referral Form

Agency Name

Contact Person Name

Address

Zip Code

Phone #

Fax #

A clear, current threat to the individual's ability to be maintained in his/her customary setting (Provide of evidence of clear, current threat to the youth's ability to be maintained in their customary setting):

An emerging/pending risk to the safety of the individual or others (Provide evidence of emerging risk to the safety of the youth or others):

Significant psychological or social impairments such as inappropriate social behaviors causing serious problems with peer relationships and/or family members (Provide evidence of significant psychological or social impairments causing serious problems with peer relationships and/or family members):

What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth's symptoms and functional behavioral impairments:

How will PRP serve to help this youth get to age appropriate development, more independent functioning and independent living skills:

Upload file if any

Referral

How to Apply For Our Services

Online Referral Form

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