Therapy Collaboration Form – Empowering Minds Resource Center

This form is only to be used for Clients currently enrolled in our PRP Program. The intent is to provide an update for continued services.

Referral Date *

Referral Contact Phone *

Referral Fax

Referral Email Address *

Referral Source Name *

Referral Source Agency *

Referral Address *

Apartment, suite, etc

City *

State *

ZIP *

CLIENT INFORMATION

Client Name *

Date of Birth *

Client's Gender *

Guardian Name *

Relationship *

Client's SSN *Please enter your Social Security Number without dashes or spaces (e.g., 123456789).0 / 9

Medicaid# *

Name of person that client is residing with *

Relationship with client *

Client Address *

Apartment, suite, etc

City *

State *

ZIP *

Home Phone *

Alternative Phone

Other important contact information (e.g. biological family)

Diagnosis *

Please indicate all services being provided and frequency of services

Check All Services *

Select Frequency *

Has medication been prescribed? *

List Medication(s)

Medication *

Dosage *0 / 10

Frequency *

Route of Administration *

Interval in Hours *Please specify the number of hours between each dose.

Indicate which of the following programs) the individual is also receiving services from *

Presenting Concerns/Progress/Comments *

Does client have a history of (check all that apply) *TraumaLegal IssuesSubstance AbuseN/A

Explain *

Has the client been referred to any other less intensive program? *YesNo

When, where, and what was the outcome? *

Referring Clinician's Credentials *

Referring Clinician's Signature *

Please ensure to put your credentials behind your signature. IT IS REQUIRED.

Supervisors Name and Credentials *

Save as Draft

Existing PRP Client Collaboration

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Harford County