Therapy Collaboration Form – Empowering Minds Resource Center

Existing Client 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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