Online Referral Form

DSM V Diagnosis: (A minor must have a behavioral diagnosis and be referred by a Licensed MH Professional to be eligible for PRP.)

Behavioral Diagnoses: (ICD-IO Diagnosis Code Required)

Primary Medical Diagnoses (required)

Functional Assessment (if applicable)

Reason for referral (indicate the areas you want the PRP to address)

Licensed Mental Health Professional Providing Referral: