PRP Referral Form

Who Should Complete This Form

This form is for licensed clinicians who have an established clinical relationship with the client and are submitting a referral for clients with eligible diagnoses to begin PRP services with King Health Systems.

Before You Begin

• Have the client, guardian (if applicable), and referring clinician information available.
• Provide clinical information, diagnoses, medications, and the client’s goals and support needs.
• Include the most current psychosocial assessment and any applicable custody orders with the referral.

The information provided supports review of medical necessity and authorization for PRP services.

Before submitting a referral, please review our Eligibility & Payment information.

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1. Referring Clinician Information

Complete all required information. Provide the most current psychosocial assessment and any applicable custody orders with the referral. Review the client, clinical, and support-needs sections before submitting.

Referring Professional’s Name *

Referring Professional Address and Phone Number *

Psychiatrist/Psych NP Name

Psychiatrist/Psych NP Address and Phone Number

2. Client and Guardian Information

Complete all required fields so medical necessity and authorization for services can be reviewed. Guardian information is optional. Include the most current psychosocial assessment and any applicable custody orders with the referral.

Type of Referral

• Initial Referral
• Concurrent Referral

Client Name *

MA Number *

Date of Birth *

Race *

Address *

Phone Number *

Sex *

• Male
• Female

Marital Status *

PCP/PED *

Parent/Guardian

Parent/Guardian Address

3. Clinical Information

Mental Health Diagnoses

Diagnostic Code *

the Diagnoses Current

Primary Medical Diagnoses

Social Elements Impacting Diagnosis *

• None
• Access to Health Care
• Housing Problems
• Social Environment
• Educational
• Legal System/Crime
• Occupational
• Homelessness
• Financial
• Primary Support
• Other Psychosocial/Environment
• Unknown

Individual experiences at least three of the following *

• Inability to maintain independent employment
• Social behavior that results in interventions by the mental health system
• Inability to procure financial assistance due to cognitive disorganization
• Severe inability to establish or maintain social supports
• Need for assistance with basic living skills

Current Medications

Is the client compliant with their medication? *

• Yes
• No
• Unknown
• N/A — Not prescribed medication

Presenting Symptoms (Please Include History of SI and HI) *

4. Goals and Support Needs

1) Self-Care Skills

• Personal Hygiene
• Grooming
• Nutrition
• Dietary Planning
• Food Preparation
• Self-Administration of Medication
• Appearance

2) Social Skills

• Community Integration Activities
• Developing Natural Supports
• Developing Linkages with and Supporting the Individual’s Participation in Community Activities
• Age-Appropriate Boundaries
• Interactive Skills with Authority Figures
• Anger Management
• Conflict Resolution
• Interactive Skills with Peers

3) Independent Living Skills

• Skills Necessary for Housing Stability
• Community Awareness
• Mobility and Transportation Skills
• Money Management
• Accessing Available Entitlements and Resources
• Supporting the Individual to Obtain and Retain Employment
• Health Promotion and Training
• Time Management, Individual Wellness Self-Management and Recovery

Provide a brief description of how PRP services will benefit the client.

Most Recent Psychiatric Hospitalization (Where and When, if Any)

Supporting Documentation (if available)

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Upload the most current psychosocial assessment and any applicable custody orders. Accepted files: PDF, JPG, JPEG, PNG, and WebP. Up to 5 files, 10 MB per file.

Referring Mental Health Professional Signature and Credentials *

5. Documents and Review: Provide the most current psychosocial assessment and any applicable custody orders with the referral. Review all required fields before submitting.

Date *

Submit