KEYS BEHAVIORAL HEALTH

Step 1 of 10

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name:(Required)

First Last

Phone Number:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Email:

Relationship to Referred:(Required)

PROVIDER INFORMATION

Is this an initial or or concurrent request?(Required)

Referring Clinician's Name:(Required)

First Last

License Type:(Required)

License Number:(Required)

Are you the clinical treatment provider for this consumer?(Required)

Do you have permission from the treating clinician to refer identified consumer for Psychiatric Rehabilitation services?(Required)

Clinical Supervisor's Name:(Required)

First Last

Clinical Supervisor's License Type:(Required)

PRP ADOLESCENT INFORMATION

Primary Diagnosis:(Required)

Is the individual eligible for full funding for Developmental Disabilities Administration services?(Required)

Have family or peer supports been successful supporting this youth?(Required)

Is the primary reason for the youth's impairment due to an organic process or syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?(Required)

Has the participant been judged to be in enough behavioral control to be safe in a PRP program and benefit from the rehab provided?(Required)

Will the youth's level of cognitive impairment, current mental status or developmental level impact their ability to benefit from PRP?(Required)

Is the youth currently in mental health outpatient or inpatient treatment?(Required)

Is the referral source in some way paid by the PRP program or receives other benefit from PRP program?(Required)

The youth has been engaged in active, documented outpatient treatment for:(Required)

DOUBLE CHECK

Frequency of Clinical Treatment:(Required)

Date of Clinical Collaboration:(Required)

How long has the youth been engaged in active, documented, outpatient treatment?(Required)

Double CHECK

In the past 3 months, how many ER visits has the youth had for psychiatric care?(Required)

Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting?(Required)

Has medication been considered for this youth?(Required)

Within the past 3 months, the emotional disturbance has resulted in:(Required)

A clear, current threat to the youth’s ability to be maintained in their customary setting

An emerging risk to the safety of the youth or others.

Significant psychological or social impairments causing serious problems with peer relationships and/or family members

Select all the apply. List objective evidence in this form, even if other evidence will be attached to this request.

Evidence of clear, current threat to the youth's ability to be maintained in their customary setting:(Required)

Evidence of emerging risk to the safety of the youth or others:(Required)

Evidence of significant psychological or social impairments causing serious problems with peer relationships and/or family members:(Required)

What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth's symptoms and functional behavioral impairments resulting from mental illness?(Required)

Has youth made progress toward age appropriate development, more independent functioning living skills?(Required)

Indicate changes in treatment plan to address lack of progress:(Required)

Describe Improvement:(Required)

How will PRP serve to help this youth get to age appropriate development, more independent functioning and independent living skills?(Required)

Has a crisis plan been completed with family and/or guardian?(Required)

Has an individual treatment plan/individual rehabilitation plan been completed?(Required)

Is the participant/guardian involved in preparation of the plan?(Required)

Is the participant/guardian in agreement of the plan?(Required)

PRP Adult Information

Primary Diagnosis:(Required)

Which type Dx does the consumer have:(Required)

Is the individual currently enrolled in SSI/SSDI?(Required)

Is the individual eligible for full funding for Developmental Disabilities Administration services?(Required)

Is the primary reason for the participant's impairment due to an organic process or syndrome, intellectual disability, a neurodevelopment disorder or neurocognitive disorder?(Required)

Is individual currently receiving mental health treatment from a licensed mental health professional or being referred from inpatient, mental health residential crisis, or mobile treatment services/assertive community treatment program?(Required)

Does the participant have marked inability to establish or maintain competitive employment?(Required)

Evidence of marked inability to establish or maintain competitive employment:(Required)

Does the participant have marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management)?(Required)

Evidence of marked inability to perform instrumental activities of daily living (eg: shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management):(Required)

Does the participant have marked inability to establish/maintain a personal support system?(Required)

Evidence of marked inability to establish/maintain a personal support system:(Required)

Does the participant have deficiencies of concentration/ persistence/pace leading to failure to complete tasks?(Required)

Evidence of deficiencies of concentration/ persistence/pace leading to failure to complete tasks:*(Required)

Is participant unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)?(Required)

Evidence of inability to perform self-care (hygiene, grooming, nutrition, medical care, safety):(Required)

Does the participant have marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities?(Required)

Evidence of marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities:(Required)

Does the participant have marked inability to procure financial assistance to support community living?(Required)

Evidence of marked inability to procure financial assistance to support community living:(Required)

Has participant demonstrated marked functional impairments for at least 2 years?(Required)

Has consideration been given to using peer supports and other informal supports such as family?(Required)

Has participant been judged to be in enough behavioral control to be safe in rehab program and benefit from the rehab provided?(Required)

List specific ways in which PRP services are expected to help this individual:(Required)

SUD ENROLLMENT

This form is being filled at the consumers:(Required)

Legal Status at Admission:(Required)

How well does the Individual Speak English? (5 years old or older)(Required)

Does the Individual Need Assistance with Communicating in English?(Required)

Does the Individual Speak a Language other than English at Home?(Required)

Did the Individual Attend School Any Time in the Past 3 Months?(Required)

Is the Individual Deaf or hard of Hearing?(Required)

Is the Individual Blind or Having Serious Difficulty Seeing, even when Wearing Glasses?(Required)

Because of a Physical, Mental, or Emotional Condition, is the Individual having Serious Difficulty Concentrating, Remembering, or Making Decisions? (5 years old or older)(Required)

Is the Individual Having Serious Difficulty Walking or Climbing Stairs? (5 years old or older)(Required)

Is the Individual Having Difficulty Dressing or Bathing? (5 years old or older)(Required)

Because of a Physical, Mental, or Emotional Condition, is the Individual Having Serious Difficulty doing Errands Alone such as Visiting a Doctor's Office or Shopping? (15 years old or older)(Required)

Was the Individual Homeless in the Last 6 Months?(Required)

Tobacco Use in the Past 30 Days(Required)

Does the Individual Smoke Cigarettes?(Required)

Was the individual screened for gambling?(Required)

Confirmation of consumer's SUD History:(Required)

Psych problem in addition to alcohol or drug:(Required)

Primary Substance of Use:(Required)

Age at First Use:(Required)

Route of Administration:(Required)

Frequency of Use:(Required)

Date of Last Use:(Required)

Signature:(Required)

Please attach documentation needed to support services for this consumer:

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB.

(Ex: Treatment Plans, Assessments, Discharge Summaries, Court Order, etc.)

PROGRAM CONSENT

Protected Health Information: KEYS understands that all protected health information (PHI) about you is personal and we are committed to protecting this information. We create a record of care and services you receive at this agency to provide you with quality care and to comply with certain legal requirements. This notice applies to all records about your care generated by KEYS.

Md. Code, Health-General § 20-104: If you are 12 years of age or older, you have the same capacity as an adult to consent to consultation, diagnosis and treatment of a mental or emotional disorder by a physician, psychologist or a clinic.

[Md. Code Ann., Health-Gen. II § 20-102(c)(1)-(5)] Psychological treatment for drug abuse or alcoholism – A minor has the capacity to consent to psychological treatment for drug abuse or alcoholism if, in the judgment of the attending physician or a psychologist, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual.

KEYS Programming: KEYS offers weekly training that assists with the development and promotion of life skills. Eligibility for some services may be contingent on participation in these groups. By selecting to participate in services you agree to attend these sessions to be deemed eligible for those services. In the event you choose NOT to participate in sessions, you understand that the services you are eligible for may be limited.(Required)

Liability Waiver:(Required)

I, hereby agree to release and hold harmless from any liability, KEYS including its paid and volunteer staff executors, administrators, and other agents representing KEYS. This waiver specifically relates to personal injury which may occur while participating in any programs or activity of any kind conducted, approved, organized, or sponsored by KEYS or its representatives. Further, that the consideration for this waiver, is the right, privilege, and opportunity for myself/my child to participate in the programs and activities conducted, approved, organized, or sponsored by KEYS.

Photo/Media Consent:

If I choose to consent and authorize KEYS to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form). I authorize KEYS to copyright the materials, and I authorize KEYS to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to university publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I agree with these items to be used up to 99 years after the initial date of use. I agree that I am participating on a voluntary basis and I will not receive any payment from KEYS for signing this release or as a result of any publication of the materials. If I choose to be photographed or recorded, I do not consent or authorize KEYS to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).

Program Participation(Required)

I give permission for myself/my youth to participate in KEYS Programming. I give permission for myself/my youth to hold conversations that discuss mental health, police brutality, healthy sex practices, positive peer relationships, and other topics that provide support and promotion for healthy development. (Md. Code, Health-General § 20-104) (If you are 12 years of age or older, you have the same capacity as an adult to consent to consultation, diagnosis and treatment of a mental or emotional disorder by a physician, psychologist or a clinic.) I do understand that there are some services that I will be eligible for and I agree to have MY INSURANCE BILLED for Case Management services.

3rd Party Consent for Data Tracking:(Required)

KEYS currently partners with several organizations working to create safer healthier communities. In order to determine where programming should take place and how funding is issued to address social determinants of health, KEYS has to share certain demographic information. Family League of Baltimore (Family League) and other community organizations funds many programs in Baltimore. We want to make sure that these programs help young people. To do this, we check on (evaluate) the programs often. With this form, we ask you to allow us to use your information as we check on your program. If you allow us, we will use some information about you, such as Name, Date of birth, Program participation records, and “Unique school ID” (Student Identification Number), if needed. Family League also works with other agencies in Baltimore City, such as Baltimore City Public Schools. We may use your information to connect to their databases (computer files) and access some or all of the information below: Gender, race, ethnicity, School day attendance, State test scores for math and reading, and iReady test scores. Plus, we may ask you to fill out a survey. This survey will ask what you think about this program. Your answers will help us check how the program is doing. No one will use your information in any other way without your permission. We will keep all your information confidential and private. Only Family League staff, researchers, and other approved funding staff will look at your information. Your program staff will not see your information. When we talk or write about what we find out, we will not share your name. We will not share parts of your information that make it easy for others to know it is you. Instead, we will talk about information about groups of people. Also, we will not use names as we check on how the program is doing. You may choose to share your information. You may also choose not to share your information. Either way, you may still take part in your program. If we give you a survey, you may choose to answer only the questions you want. You may also choose to answer no questions. No money will be paid for letting us use your information or answering our questions. We hope to get information that will make this program better. As programs get better, they will help more people. If additional information is needed contact info@keysdev.com.

DEMOGRAPHIC INFORMATION

REFERS INFORMATION

PRIMARY CARE PHYSICIAN

EMERGENCY CONTACT INFORMATION

PRP ENROLLMENT

PROVIDER INFORMATION

PRP ADOLESCENT INFORMATION

PRP Adult Information

OMHC ENROLLMENT

SUBSTANCE ABUSE INFORMATION

SUD ENROLLMENT

PROGRAM CONSENT