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Rehabilitation Center
for Humanity

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Client Referrals

If you would like to refer an individual for services provided by RCH, please complete the below listed referral questions. A representative will respond to you within 48 business hours.

Select a date

First Name

Last Name

Email

Phone

Date of Birth

Sex

Male

Female

Gender Expansive

Fluid

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Race

Black

White

Hispanic

Other

MA #

School Attending

Current/Highest Grade Level Completed

Marital Status

Single

Married

Divorced

Widowed

Resides With

Mother

Father

Guardian

N/A

Parent/Guardian Name

Relationship

Does parent/guardian have legal custody of the child?

Yes

No

N/A

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Please provide specific examples of functional impairments caused by diagnosis.

Is the client currently in mental health inpatient or outpatient treatment?

Yes

No

Inpatient/Outpatient Provider Name

The client has been engaged in active docmented outpatient treatment for

Less than a month

Between one and three months

Six months or more

N/A

In the past three months, how many ER visits has the client had for psychiatric care?

No visits in the last three months

One visit in the last three months.

Two or more visits in the last three months.

Is the client transitioning from an inpatient day hospital or residential treatment setting to a community setting?

Yes

No

Substance Abuse?

Yes

No

Legal Involvement?

Yes

No

Previous/Current Suicidal Ideation?

Yes

No

Is the client currently taking medication?

Yes

No

If yes, please provide medication list. If no, please type N/A

Is the client employed? Has the client been referred to supported employment? Plese explain.

Can the client maintain competitive employment? Why or why not?

Can the client perform activities of daily living? (Examples are shopping, meal prep, housekeeping, laundry, transportation, transportation, money management)

Can the client maintain a support system? Please explain.

Can the client concentrate or do they have issues leading to failure to complete task? Please explain.

Is the client unable to perform self care (hygiene, grooming, nutrition, medical care) Please explain.

Does the client have named deficiencies in self direction? Inability to plan, organize goals? Please explain.

Does the client have named inability to obtain money/financial support for community living? Please explain.

Has peer supports/family been supportive? Group therapy or case management? Please explain.

Primary Behavioral ICD-10-CM Code

Primary Medical DX

Please explain how the Psychiatric Rehabilitation Program (PRP) can provide assistance with the above marked services and how PRP can help the consumer manage their disorder and to support recovery as it relates to their treatment goals:

Referring Agency Name

Referring Clinician/Credentials:

Supervising Clinician. If none, please type N/A

Refering Clinician's Phone Number

Referring Clinician's Email

I, agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Connect

info@rchprpservices.com

Visit

4200 Edmondson Ave. Ste. 103

Baltimore, MD, 21229

(410) 362-2983

Fax (410) 510-1681

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