2 Referral source

Name of person / agency making referral

Heuristic Therapeutic Services, LLC

Address

19707 Executive Park Circle Germantown, MD, 20874

Mental health treatment being provided

Outpatient Mental Health Services

Inpatient Mental Health Services

Residential Treatment Center

3 Consumer information

4 Parent / guardian information

5 Behavioral diagnoses (adult only)

This form must be filled out in its entirety in order to allow for medical necessity and authorization for services. Please do not add diagnoses to the form.

6 Social elements impacting diagnosis

7 Individual experiences (at least three of the following)

8 Current medications

Presenting Symptoms: Please include hx of Severity of Illness and History of Illness: Client has a history of depression, hospitalizations, SI and anxiety. Client lacks a social support system and has strained/conflictual relationships with her adult children and their fathers. Client has been unemployed for several years due to ongoing chronic pain and medical conditions. Client has been applying and appealing for disability for the past few years and struggles financially.

9 Reason for referral

(Indicate the areas you want the PRP to address.)

1) Self-care skills

2) Social skills

3) Independent living skills

10 Mental health practitioner

Attach a “Professional Assertion of Need for PRP Services”, copy of the current Treatment Plan, current Psychiatric Evaluation, Current Crisis Plan-if client is at risk for suicide, homicide or runaway status, If client is in Foster care or in DSS custody please provide copy of court papers showing guardianship