Therapy Collaboration Form – Empowering Minds Resource Center

Therapy Collaboration PRP Services Form

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

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Locations

Corporate Office

10451 Mill Run Circle
Suite 407
Owings Mills, Maryland 21117
Phone: 410-363-3713
Fax: 410-363-3715

Baltimore City

1800 North Charles Street, Suite 600
Baltimore, Maryland 21201
Phone: 410-625-5088
Fax: 410-625-4980

Baltimore County

3104 Lord Baltimore Drive,
Suite 103
Windsor Mill, Maryland 21244
Phone: 443-893-3928
Fax: 443-200-5032

Prince George’s County

5808 Allentown Way
Temple Hills, Maryland 20748
Phone: 240-719-3968
Fax: 240-838-7040

Harford County

1833A Pulaski Hwy
Edgewood, Maryland 21040
Phone: 443-484-2306
Fax: 443-484-2970

Anne Arundel County

7954 Baltimore Annapolis Blvd
Suite E & F
Glen Burnie, Maryland 21061
Phone: 410-590-3672
Fax: 410-590-3670

Resource Center

105 East 25th Street Baltimore, Maryland 21218
Phone: 410-467-5550
Fax: 410-467-4679

Certification and Accreditation

Referral Line

410-246-0169

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