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Psychiatric Rehabilitation Services and Supported Living Services are designed for adults with chronic and persistent mental illness to help them regain and maintain independence within the community. These services include life skills teaching, day program services, vocational services, and in some cases housing. The Supported Living Program offers additional in-home supports, intensive case management, landlord mediation, financial and medication management, and much more. An individual can be a part of either the PRP Day Program or Supported Living or both.Applications can be faxed to Jesse Guercio, Director of Behavioral Health Services 410-381-5317, emailed to BHAdmin@, or mailed to the address below.Individual’s Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(Last)(First)(Middle)Individual’s Address: FORMTEXT ?????Home #: FORMTEXT ?????Mobile #: FORMTEXT ?????Email: FORMTEXT ?????Sex: FORMCHECKBOX Female FORMCHECKBOX Male Race: FORMCHECKBOX Caucasian FORMCHECKBOX African American FORMCHECKBOX Hispanic FORMCHECKBOX Asian FORMCHECKBOX OtherDOB: FORMTEXT ????? Age: FORMTEXT ????? Medical Assistance #: FORMTEXT ????? MCO: FORMTEXT ?????In order to qualify for services the individual must meet one of the following DSM 5 diagnosesPrimary Behavioral Health Diagnosis (check all that apply):ICD-9ICD-10DSM 5 DiagnosisICD-9ICD-10DSM 5 Diagnosis FORMCHECKBOX 295.90F20.9Schizophrenia FORMCHECKBOX 296.43F31.13Bipolar I Disorder, Current or Most Recent Episode, Manic, Severe without Psychotic Features FORMCHECKBOX 295.40F20.81Schizophreniform Disorder FORMCHECKBOX 296.44F31.2Bipolar I Disorder, Current or Most Recent Episode, Manic, Severe with Psychotic Features FORMCHECKBOX 295.70F25.0Schizoaffective Disorder, Bipolar Type FORMCHECKBOX 296.53F31.4Bipolar I Disorder, Current or Most Recent Episode, Depressed, Severe without Psychotic Features FORMCHECKBOX 298.8F28Schizoaffective Disorder, Depressive Type FORMCHECKBOX 296.54F31.5Bipolar I Disorder, Current or Most Recent Episode, Depressed, Severe with Psychotic Features FORMCHECKBOX 298.9F29Other Specified Schizophrenia Spectrum and Other Psychotic Disorder FORMCHECKBOX 296.40F31.0Bipolar I Disorder, Current or Most Recent Episode, Hypomanic FORMCHECKBOX 297.1F22Unspecified Schizophrenia Spectrum and Other Psychotic Disorder FORMCHECKBOX 296.40F31.9Bipolar I Disorder, Current or Most Recent Episode, Hypomanic, Unspecified FORMCHECKBOX 296.33F33.2Major Depressive Disorder, Recurrent Episode, Severe without Psychotic Features FORMCHECKBOX 296.7F31.9Bipolar I Disorder, Current or Most Recent Episode, Unspecified FORMCHECKBOX 296.34F33.3Major Depressive Disorder, Recurrent Episode, Severe with Psychotic Features FORMCHECKBOX 296.89F31.81Bipolar II Disorder FORMCHECKBOX 301.22F21Schizotypal Personality Disorder FORMCHECKBOX 301.83F60.3Borderline Personality DisorderThe diagnostic criteria may be waived for either one of the following two conditions: FORMCHECKBOX An individual committed as not criminally responsible who is conditionally released from a Mental Hygiene facility, according to the provisions of Health General Article, Title 12, Annotated Code of Maryland FORMCHECKBOX An individual in a Mental Hygiene facility (including Residential Treatment Center) with a length of stay of more than 6 months who requires RRP services. This excludes individuals eligible for Developmental Disabilities services.Social Elements Impacting Diagnosis (Check all that apply): FORMCHECKBOX None FORMCHECKBOX Access to Health Care FORMCHECKBOX Housing Problems FORMCHECKBOX Social Environment FORMCHECKBOX Educational FORMCHECKBOX Legal System/Crime FORMCHECKBOX Occupational FORMCHECKBOX Homelessness FORMCHECKBOX Financial FORMCHECKBOX Primary Support FORMCHECKBOX Other Psychosocial/Enviro. FORMCHECKBOX Unknown Individual experiences at least 3 of the following: FORMCHECKBOX Inability to maintain independent employment FORMCHECKBOX Severe inability to establish or maintain social supports FORMCHECKBOX Social behavior that results in interventions by the mental health system FORMCHECKBOX Need or assistance with basic living skills FORMCHECKBOX Inability, due to cognitive disorganization, to procure financial assistance to support living in the communityIf the individual has a co-occurring Substance Use Disorder (cannot be primary diagnosis)ICD-9ICD-10DSM 5 DiagnosisICD-9ICD-10DSM 5 Diagnosis FORMCHECKBOX 305.00F10.10Alcohol Use Disorder – Mild FORMCHECKBOX 304.20F14.20Stimulant-Related Disorder – Cocaine – Severe FORMCHECKBOX 303.90F10.20Alcohol Use Disorder – Moderate FORMCHECKBOX 305.70F15.10Stimulant-Related Disorder – Amphetamine-type substance – Mild FORMCHECKBOX 303.90F10.20Alcohol Use Disorder – Severe FORMCHECKBOX 304.40F15.20Stimulant-Related Disorder – Amphetamine-type substance – Moderate FORMCHECKBOX 305.20F12.10Cannabis Use Disorder – Mild FORMCHECKBOX 304.40F15.20Stimulant-Related Disorder – Amphetamine-type substance – Severe FORMCHECKBOX 304.30F12.20Cannabis Use Disorder – Moderate FORMCHECKBOX 305.1Z72.0Tobacco Use Disorder – Mild FORMCHECKBOX 304.60F12.20Cannabis Use Disorder – Severe FORMCHECKBOX 305.1F17.200Tobacco Use Disorder – Moderate FORMCHECKBOX 305.50F11.10Opioid Use Disorder – Mild FORMCHECKBOX 305.1F17.200Tobacco Use Disorder – Severe FORMCHECKBOX 304.00F11.20Opioid Use Disorder – Moderate FORMCHECKBOX 305.90F19.10Other (or Unknown) Substance Use Disorder – Mild FORMCHECKBOX 304.00F11.20Opioid Use Disorder – Severe FORMCHECKBOX 304.90F19.20Other (or Unknown) Substance Use Disorder – Moderate FORMCHECKBOX 305.60F14.10Stimulant-Related Disorder – Cocaine – Mild FORMCHECKBOX 304.90F10.20Other (or Unknown) Substance Use Disorder – Severe FORMCHECKBOX 304.20F14.20Stimulant-Related Disorder – Cocaine – Moderate FORMCHECKBOX 304.20F14.20Stimulant-Related Disorder – Cocaine – SevereInclude any secondary Behavioral Health Diagnoses (If any): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Medical Diagnoses (If any): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Reason for Referral:Self-care skills: FORMCHECKBOX Personal hygiene, FORMCHECKBOX Grooming FORMCHECKBOX Nutrition FORMCHECKBOX Dietary planning FORMCHECKBOX Food preparation FORMCHECKBOX Self administration of medicationOther: FORMTEXT ?????Social Skills: FORMCHECKBOX Community integration activities FORMCHECKBOX Developing natural supports FORMCHECKBOX Developing linkages with and supporting the individual’s participation in community activities.Other: FORMTEXT ?????Independent Living Skills: FORMCHECKBOX Skills necessary for housing stability FORMCHECKBOX Community awareness FORMCHECKBOX Mobility and transportation skills FORMCHECKBOX Money management FORMCHECKBOX Accessing available entitlements and resources FORMCHECKBOX Supporting the individual to obtain and retain employment FORMCHECKBOX Health promotion and training FORMCHECKBOX Individual wellness self management and recovery.Other: FORMTEXT ?????Other: FORMTEXT ?????Any additional information that you feel would be helpful in serving this individual: FORMTEXT ?????Who is making this referral: FORMCHECKBOX Self FORMCHECKBOX Family FORMCHECKBOX Case Manager FORMCHECKBOX Other Contact Information of the person making referral (if not self):Name: FORMTEXT ????? Phone: FORMTEXT ?????Psychiatrist: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Therapist: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Primary Care: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Check all that apply: FORMCHECKBOX I am referring this person for Psychiatric Rehabilitation Day Services (day program) FORMCHECKBOX I am referring this person for Supported Living Services (in-home supports & case management)__________________________________________________Referring Clinician’s Name & Credentials(Print)___________________________________________________________________Referring Clinician’s SignatureDate ................
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