Make a Referral to the PREP Team PREP Team Referral Form InstructionsWHO SHOULD USE THIS FORM?- Individuals who are interested in submitting their OWN information to the PREP team- Individuals who are referring a friend or family member to the PREP team - Medical or Behavioral Health professionals who are referring another person to the PREP team.INFORMATION TO KNOW BEFORE SENDING A REFERRAL-The PREP Team works with youth and young adults between the ages of 13 - 26 years old who are at high risk of developing a psychotic disorder or have been diagnosed with a psychotic disorder within the last 18 months. (If your client does not meet the criteria, we may be able to provide consultation on the case) - A referral to the PREP Team does not guarantee treatment.-The PREP Team will complete an evaluation when appropriate to determine eligibility. - Common reasons for disqualification are: IQ score under 70; psychotic symptoms due to substance use disorder; psychotic symptoms due to another mental health diagnosis; psychosis due to a medical condition; or not following within the required age range of 13 to 26 years old.STEP 1: INFORMATION ABOUT WHO IS COMPLETING THIS FORM Name of person completing this form*FirstLast Relationship to Person being Referred:*Choose OneSelfParentProfessional-Behavioral HealthProfessional-other MedicalOther Phone Number(1)* Area Code - Phone Number Email of Person Completing Form*STEP 2: INFORMATION ABOUT THE PERSON BEING REFERRED TO THE PREP TEAM Name*FirstLast Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Please check if the Date of Birth is unknown. DOB is unknown Phone Number* Area Code - Phone Number Email* How would you prefer to be contacted?Choose PreferencePhoneEmail Add WBH ID # (If Applicable) Add Current Therapist & Clinic (If Applicable)STEP 3: SYMPTOMS Approximate Date of Onset Symptoms (Month/ Year)* Current Diagnoses & Mental Health Symptoms* Relevant History* Physical Health Information * Substance Use Information*STEP 4: DEMOGRAPHICS Race*Alaska NativeAmerican IndianBlack or African AmericanWhiteAsianNative Hawaiian or Other Pacific IslanderHispanic or LatinoUnknownOther Current Living Situation*Transient/HomelessFoster HomeResidential FacilityJail/PrisonLives aloneAlcohol/Drug Free HousingLives w/ RelativeSupported HousingLives w/ Non-RelativeUnknownother Gender Orientation*FemaleMaleNon-binary Age at Referral Age otherSTEP 5: Prime Questionnaire & Submit Form Has the client completed a PRIME or PQ-B? *YesNoUnknown UPLOAD FILES: If you selected yes & a screening has been completed, please upload with this referral below by selecting the "arrow icon":SubmitReset PREP Team Referral Form InstructionsWHO SHOULD USE THIS FORM?- Individuals who are interested in submitting their OWN information to the PREP team- Individuals who are referring a friend or family member to the PREP team - Medical or Behavioral Health professionals who are referring another person to the PREP team.INFORMATION TO KNOW BEFORE SENDING A REFERRAL-The PREP Team works with youth and young adults between the ages of 13 - 26 years old who are at high risk of developing a psychotic disorder or have been diagnosed with a psychotic disorder within the last 18 months. (If your client does not meet the criteria, we may be able to provide consultation on the case) - A referral to the PREP Team does not guarantee treatment.-The PREP Team will complete an evaluation when appropriate to determine eligibility. - Common reasons for disqualification are: IQ score under 70; psychotic symptoms due to substance use disorder; psychotic symptoms due to another mental health diagnosis; psychosis due to a medical condition; or not following within the required age range of 13 to 26 years old.STEP 1: INFORMATION ABOUT WHO IS COMPLETING THIS FORM Name of person completing this form*FirstLast Relationship to Person being Referred:*Choose OneSelfParentProfessional-Behavioral HealthProfessional-other MedicalOther Phone Number(1)* Area Code - Phone Number Email of Person Completing Form*STEP 2: INFORMATION ABOUT THE PERSON BEING REFERRED TO THE PREP TEAM Name*FirstLast Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Please check if the Date of Birth is unknown. DOB is unknown Phone Number* Area Code - Phone Number Email* How would you prefer to be contacted?Choose PreferencePhoneEmail Add WBH ID # (If Applicable) Add Current Therapist & Clinic (If Applicable)STEP 3: SYMPTOMS Approximate Date of Onset Symptoms (Month/ Year)* Current Diagnoses & Mental Health Symptoms* Relevant History* Physical Health Information * Substance Use Information*STEP 4: DEMOGRAPHICS Race*Alaska NativeAmerican IndianBlack or African AmericanWhiteAsianNative Hawaiian or Other Pacific IslanderHispanic or LatinoUnknownOther Current Living Situation*Transient/HomelessFoster HomeResidential FacilityJail/PrisonLives aloneAlcohol/Drug Free HousingLives w/ RelativeSupported HousingLives w/ Non-RelativeUnknownother Gender Orientation*FemaleMaleNon-binary Age at Referral Age otherSTEP 5: Prime Questionnaire & Submit Form Has the client completed a PRIME or PQ-B? *YesNoUnknown UPLOAD FILES: If you selected yes & a screening has been completed, please upload with this referral below by selecting the "arrow icon":SubmitReset
