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RESIDENTIAL REHABILITATION PROGRAM APPLICATION FORM INSTRUCTIONS (Prince George's County/Office of Information Technology and Communications)

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1
RESIDENTIAL REHABILITATION PROGRAM
APPLICATION FORM INSTRUCTIONS
Residential Rehabilitation Program (RRP) provides housing and supportive services to single individuals. The goal of residential
rehabilitation is to provide services that will support an individual to transition to independent housing of their choice.
Residential Rehabilitation Programs provide staff support around areas of personal needs such as medication monitoring,
independent living skills, symptom management, stress management, relapse prevention planning with linkages to
employment, education and/or vocational services, crisis prevention and other services that will help with the individual’s
recovery.
Please see the enclosed Residential Rehabilitation Program (RRP) application.
• It is recommended that the mental health professional and/or mental health provider who works most closely with
the applicant complete the application.
• Applicant must sign the RRP Consent For Release of Information Form.
• Medical Necessity Criteria must indicate why the applicant cannot function independently in the community with
other mental health services. There are two levels of care for which an applicant may apply: Intensive or General.
The application will not be reviewed by the CSA if the Medical Necessity Criteria is incomplete or has not been met.
• Priority is given to in-county residents
. If the applicant wishes to be referred to another county’s RRP, please state no
more than three (3) specific jurisdictions on the RRP Consent for Release of Information Form.
• If the applicant needs a specialty service
, please review the following grid to determine that service:
SERVICE
CSA JURISDICTION
TAY
(Transitional Age Youth)
Baltimore City
Baltimore County
Carroll County
Frederick County
Howard County
Montgomery County
Prince George’s County (ages 16-24, single parent with no more than
4 children)
DD/MH
(Developmental Disability/Mental Health)
Anne Arundel County (accessed through a state hospital)
Carroll County
Frederick County (include copy of DDA letter stating applicant’s
eligibility for ISS or SO funding)
St. Mary’s County
ITCOD
(Integrated Treatment for Co-Occurring Disorders)
Frederick County
Montgomery County
DEAF AND/OR HARD OF HEARING
Anne Arundel County
Baltimore City
Baltimore County
Frederick County
Prince George’s County
GERIATRIC
Anne Arundel County
Baltimore City
Frederick County
Prince George’s County
Wicomico County
• This referral does not guarantee placement. RRP providers interview eligible applicants as vacancies occur (as
directed by the Core Service Agency).
• Questions regarding program vacancies should be directed to the Core Service Agency.
• Please submit only pages 3-10 to the Core Service Agency. Discard pages 1-2 and pages 11-12 (these pages are not
necessary and are not required by the Core Service Agency).
• The application must be sent to the Core Service Agency of the applicant’s home origin (based upon the applicant’s
current or last known address in the community prior to inpatient hospitalization, incarceration, residential crisis
bed or current state of homelessness). The application can be mailed and/or faxed to the Core Service Agency
address (mail) or the Core Service Agency fax number (fax). Please mark the envelope or fax cover sheet: Attn:
Adult Services Coordinator or
Residential Specialist.
Revised:\BHA\AdultServices\RRPapp\09\01\17
2
CORE SERVICE AGENCIES :
ALLEGANY COUNTY
Allegany Co. Mental Health System's Office
P.O. Box 1745
Cumberland, Maryland 21501-1745
Phone: 301-759-5070 Fax: 301-777-5621
ANNE ARUNDEL COUNTY
Anne Arundel County Mental Health Agency
1 Truman Parkway, Suite 101
Annapolis, Maryland 21401
Phone: 410-222-7858 Fax: 410-222-7881
BALTIMORE CITY
Behavioral Health System Baltimore
One North Charles Street, Suite 1300
Baltimore, Maryland 21201-3718
Phone: 410-637-1900 Fax: 410-637-1911
BALTIMORE COUNTY
Bureau of Behavioral Health of Baltimore County Health
Department
6401 York Road, Third Floor
Baltimore, Maryland 21212
Phone: 410-887-3828 Fax: 410-887-3786
CALVERT COUNTY
Calvert County Core Service Agency
P.O. Box 980
Prince Frederick, Maryland 20678
Phone: 410-535-5400 #330 Fax: 410-414-8092
CARROLL COUNTY
Carroll County Health Department
Bureau of Prevention, Wellness, and Recovery
290 South Center Street
Westminster, Maryland 21158-0460
Phone: 410-876-4800 Fax: 410-876-4832
CECIL COUNTY
Cecil County Core Service Agency
401 Bow Street
Elkton, Maryland 21921
Phone: 410-996-5112 Fax: 410-996-5134
CHARLES COUNTY
Department of Health
Core Service Agency
P.O. Box 1050, 4545 Crain Hwy.
White Plains, Maryland 20695
Phone: 301-609-5757 Fax: 301-609-5749
FREDERICK COUNTY
Mental Health Management Agency of Frederick County
22 South Market Street, Suite 8
Frederick, Maryland 21701
Phone: 301-682-6017 Fax: 301-682-6019
GARRETT COUNTY
Garrett County Core Service Agency
1025 Memorial Drive
Oakland, Maryland 21550-1943
Phone: 301-334-7440 Fax: 301-334-7441
HARFORD COUNTY
Office on Mental Health of Harford County
125 N Main Street
Bel Air, Maryland 21014
Phone: 410-803-8726 Fax: 410-803-8732
HOWARD COUNTY
Howard County Mental Health Authority
8930 Stanford Boulevard
Columbia, Maryland 21045
Phone: 410-313-7350 Fax: 410-313-7374
MID-SHORE COUNTIES
(Includes Caroline, Dorchester, Kent,
Queen Anne and Talbot Counties)
Mid-Shore Mental Health Systems, Inc.
28578 Mary’s Court, Suite 1
Easton, Maryland 21601
Phone: 410-770-4801 Fax: 410-770-4809
MONTGOMERY COUNTY
Department of Health & Human Services
Montgomery County Government
401 Hungerford Drive, 1st Floor
Rockville, Maryland 20850
Phone: 240-777-1400 Fax: 240-777-1628
PRINCE GEORGE’S COUNTY
Prince George’s County Health Department
Behavioral Health Services
Prince George's County Core Service Agency
9314 Piscataway Road
Clinton, Maryland 20735
Phone: 301-856-9500 Fax: 301-856-9558
SOMERSET COUNTY
Somerset County Core Services Agency
Somerset County Health Department
7920 Crisfield Highway
Westover, Maryland 21871
Phone: 443-523-1786 Fax: 410-651-3189
ST. MARY'S COUNTY
St. Mary's County Local Behavioral Health Authority
St. Mary's County Health Department
21580 Peabody Street, P.O. Box 316
Leonardtown, Maryland 20650
Phone: 301-475-4330 Fax: 301-475-9434
WASHINGTON COUNTY
Washington County Mental Health Authority
339 E. Antietam Street, Suite #5
Hagerstown, Maryland 21740
Phone: 301-739-2490 Fax: 301-739-2250
WICOMICO COUNTY
Wicomico Behavioral Health Authority
108 East Main Street
Salisbury, Maryland 21801
Phone: 410-543-6981 Fax: 410-219-2876
Revised:BHA\AdultServices\RRPapp\09\01\17
WORCESTER COUNTY
Worcester County Core Service Agency
P.O. Box 249
Snow Hill, Maryland 21863
Phone: 410-632-3366 Fax: 410-632-0065
APPLICATION FOR RESIDENTIAL REHABILITATION SERVICES Date: ____/____/____
APPLICANT’S HOME ORIGIN: Please select the applicant’s home county/city (based upon the applicant’s current or last known address in
the community prior to inpatient hospitalization, incarceration, residential crisis bed or state of homelessness, i.e., eviction, couch-surfing, motel, etc.
Allegany
Calvert
Mid-Shore (Caroline, Dorchester, Kent
Queen Anne's, Talbot)
St. Mary's
Anne Arundel
Carroll
Montgomery
Washington
Baltimore City
Cecil
Prince George’s
Wicomico
Baltimore County
Charles
Somerset
A. Applicant Information: Please complete this section. If there is a section that is unknown to the referral source, indicate with “N/A”.
Applicant’s Name:
Last: _______________________________
First: __________________________
M.I. ________
Address: (Current or Last Known Address for Applicant)
Please check if address is: Shelter Temporary housing
Phone Number(s):
Home: ____________________________
Mobile: ____________________________
Alternate: ____________________________
Homeless: Yes No
Veteran: Yes No
Date of Birth: / / Age: _________
Social Security #: _______ / _______ / _______
Gender: Male Female
Transgender
Sexual Orientation (Optional): _______________
Race: _________________________ Marital Status: ___________________
Primary Language: _______________________ Interpreter Required: Yes No U.S. Citizen Legal Resident
Current Entitlements and Income (Fill in amounts and/or insurance numbers)
Type of Income
Amount of Income (Monthly)
Status of Income (Please check response):
Supplemental Security Income (SSI)
$ ______________
Active Inactive Pending
Social Security Disability Insurance (SSDI)
$ ______________
Active Inactive Pending
Temporary Disability Allowance Program (TDAP)
$ ______________
Active Inactive Pending
Veteran’s Benefit (VA)
$ ______________
Active Inactive Pending
Employment Earnings
$ ______________
# of Hours Worked: ______________
Other Income: ______________________
$ ______________
Active Inactive Pending
NONE (No income/benefit)
No income\benefit
Type of Insurance
Insurance #
Status of Insurance (Please check response):
Medical Assistance (MA)
_______________________________________
Active Inactive Pending
Medicare (MC)
_______________________________________
Active Inactive Pending
Other Insurance:
__________________________________ _______________________________________
Active Inactive Pending
NONE (No insurance)
No Insurance
SNAP (Food Stamps) Yes No
Amount: $ ________________
Special Needs of Applicant:
Please check your response:
Does applicant require a 1
st
floor and/or ground floor placement in a RRP setting?
Yes No
Does applicant have a functional impairment that affects his/her ability to perform daily functions
and/or activities of daily living (ADLs)? Yes No
If Yes, please explain: ___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please check if applicable:
Deaf or Hard of Hearing
Blind or Low Vision
Does applicant require an assistive device?
Assistive device: Any device that is designed, made, or adapted to assist a person to perform a particular
task. Examples: canes, crutches, walkers, wheelchairs, shower chairs, etc.
Yes No
If Yes, please explain: ________________________
___________________________________________
Does applicant require an adaptive device?
Adaptive device: Any structure, design, instrument, or equipment that enables a person with a disability to
function independently. Examples: plate guards, grab bars, transfer boards (also called self-help device).
Yes No
If Yes, please explain: ________________________
___________________________________________
Revised: BHA\AdultServices\RRPapp\09\01\17
3
Worcester
B. Referral Source – Mental Health Professional or Mental Health Provider
Name/Title:
____________________________________
____________________________________
Agency:
______________________________________
Contact Information:
Telephone #:
__________________________
Fax #:
__________________________
Email:
_________________________
Psychiatrist Name:
Telephone #:
Current Providers (Mobile Treatment, Psychiatric Rehabilitation Program, Case Management, Outpatient Mental Health Center, Supported
Employment)
Name of Program
Contact Person
Telephone #
Primary Contact (Examples: Applicant (self), therapist, family member, friend, legal guardian, other)
Name of Contact:
Telephone #:
Relationship to Applicant:
C. Psychiatric Information: Please provide the psychiatric and/or substance use disorder of the applicant.
(Please see Attachment #
2
: Priority Population Diagnoses \ Substance Use Disorders)
The Priority Population Diagnosis (es) (PPD) must be present on the first line. Place
other diagnoses on the next lines – Substance Use Disorder(s), Medical Disorder(s) (if
applicable). Place diagnoses in order of clinical importance.
INTERNATIONAL CLASSIFICATION
OF DISEASES (ICD) CODE:
Primary: ___________________________________________________________
Secondary: ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Medical Dx: ___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Other Conditions that may be a Focus of Cli
nical Attention:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
D. Substance Use Information:
Substance Use History
Previous history of drug use
(including alcohol)
Date(s) Used
Amount
How Used (Smoked, IV, etc.)
Revised: BHA\AdultServices\RRPapp\09\01\17
4
Drug Last Used (including
alcohol)
Date(s) Used
Amount
How Used (Smoked, IV, etc.)
Previous Treatment History for Substance Use Disorder(s)
Date(s)
Detox:
Inpatient Services:
Outpatient Services:
Is treatment for the substance use disorder(s) recommended for the applicant? Yes No
Does the applicant agree to treatment for the substance use disorder(s)? Yes No
E. Medications: Please indicate the applicant’s ability to take medications. If applicant is prescribed medications, please include one of the
following: medication order sheet, medication administration record, or use Attachment #1: List of Current Medications.
Independently:
With reminders:
With daily supervision:
Refuses medications:
Medications not prescribed:
Please describe your selection for the applicant’s ability to take medications. If there is an issue of medication non-compliance, please
explain:
F. Legal Information: This section must be completed by the referral source.
Has the applicant ever been arrested?
Yes No
On Probation or Parole?
Yes No
List current charges:
List any reported convictions:
Parole or Probation Officer’s Name:
Telephone #:
Has Applicant Been Found NCR (Not Criminally Responsible) by
the court/judge:
Yes No Unknown
Is applicant currently on a Conditional Release Order from the
court/judge?
Yes (Active) Yes (Pending) Not Applicable
Expiration Date of Conditional Release Order: _____ / _____ / _____
Community Forensic Aftercare Program (CFAP): (For applicants who have been adjudicated by the court as Not Criminally
Responsible)
CFAP Monitor’s Name: ________________________________________________ Telephone #: _____________________________
Is applicant required to register thru the MD Sex Offender Registry? Yes No
Tier Level of Sex Offense as identified by the MD Sex Offender Registry: Tier I Tier 2 Tier 3
G. Risk Assessment Information: This section must be completed by the referral source.
Risk Assessment
Never
Past 2+
Years
Past
Month-
Year
Past
Week-
Month
Please provide specific details of each item.
Suicide Attempts:
Suicidal Ideation:
Aggressive Behavior/Violence:
Fire Setting/Arson:
Sexual behavior(s) that are/were non-
consensual, injurious, high risk,
forcible, Pedophilia, Paraphilia, etc.
Self-injurious behavior or self-
mutilation (not suicidal)
Revised: BHA\AdultServices\RRPapp\09\01\17
5
H. Previous RRP Experience(s):
Previous RRP Involvement: Yes
No
If yes, name of
previous RRP provider with dates: ___________________ _______________ ____________ _______________ _
If yes, reason for discontinuation of RRP: _______________________________________________________________________________
Consumer Preference of RRP Provider:
Cultural Preference of Consumer:
I. Recommended L
evel of Residential Placement: Referral source must check recommended level.
General Level
:
Staff is available on
-
call 24/7 and provides at a minimum, three face
-
to
-
face contacts per Individual, per week, or
13 face-to-face contacts per month.
Intensive Level: Staff provides services daily on-site in the residence, with a minimum of 40 hours per week, up to 24 hours a
day, 7 days a week.
If the applicant requires Intensive 24/7 bed level, please provide specific reasons why the applicant needs additional services
beyond the scope of what is provided in the Intensive bed level
(Please use Section L on page #8)
J. Medical Neces
sity Criteria: All applicants must meet Medical Necessity Criteria for a Residential Rehabilitation Program.
Please state the applicant’s rehabilitation needs below in order to demonstrate Medical Necessity for this service. The
specified requirements for severity of need and intensity must be met to satisfy the criteria for admission.
Please state clearly the description for each admission criteria for residential rehabilitation services at the GENERAL
Level or the INTENSIVE Lev
el. Unacceptable responses include: Yes, No, Cannot, Maybe, etc.
GENERAL level: Please complete items 1 - 5 of the Admission Criteria
INTENSIVE leve
l: Please complete items 1 - 6 of the Admission Criteria
Admission Criteria
Please write and/or type your response which justifies the specific
admission criteria:
1
. The consumer has a P
BHS specialty mental health
diagnosis (Priority Population Diagnosis) which is
the
cause of significant functional and psychological
impairment, and the individual’s condition can be
expected to be stabilized through the provision of
medically necessary supervised residential services in
conjunction with medically necessary treatment,
rehabilitation, and support.
Priority Population Diagnosis (Primary):
_______________
____________________________________________________
2
.
The individual requires active support to ensure the
adequate, effective coping skills necessary to live
safely in the
community, participate in self-care and
treatment, and manage the effects of his/her illness.
As a result of the individual’s clinical condition
(impaired judgment, behavior control, or role
functioning) there is significant current risk of one of the
following:
• Hospitalization or other inpatient care as
evidenced by the current course of illness or
by the past history of the illness
• Harm to self or others as a result of the
mental illness and as evidenced by the
current behavior or past behavior.
• Deterioration in functioning in the absence of
a supported community-based residence that
would lead to the other items
Previous: List psychiatric hospitalizations including name of the hospital and dates of
admission (if known):
Current: List psychiatric hospitalization including name of the hospital and date of
admission (if known):
Please provide additional information (justification) for #2:
3
. The individual’s own resources and social support
system are not adequate to provide the level of
residential support and supervision currently needed as
evidenced for example, by one of the following:
Please provide additional information (justification) for #3:
Revised: BHA\AdultServices\RRPapp\09\01\17
6
• The individual has no residence and no
social support
• The individual has a current residential
placement, but the existing placement
does not provide sufficiently adequate
supervision to ensure safety and ability to
participate in treatment; or
• The individual has a current residential
placement, but the individual is unable to
use the existing residence to ensure
safety and ability to participate in
treatment, or the relationships are
dysfunctional and undermine the stability
of treatment
4. Individual is judged to be able to reliably
cooperate with the rules and supervision provided
and to contract reliably for safety in the supervised
residence.
Please provide additional information (justification) for #4:
5. All less intensive levels of treatment have been
determined to be unsafe or unsuccessful.
Please complete the chart in the right column. ►
Service Type
Provider
Outcome
Case Management
Outpt. Mental Health Ctr.
PMHS Provider (private
practice/office)
Psych. Rehab. Program
Partial Hospital Program
A.C.T.\Mobile Treatment
Residential Crisis Bed
Emergency Room
6. The Individual has a history of at least one of the
following:
• Criminal behavior
• Treatment and/or medication non-
compliance
• Substance use
• Aggressive behavior
• Psychiatric hospitalizations
• Psychosis
• Poor reality testing
AND
Current presentation of at least one of the
following behaviors or risk factors that require
daily structure and support in order to manage:
• Safety risk
• Active delusions
• Active psychosis
• Poor decision making skills
• Impulsivity
• Inability to perform activities of daily living
skills necessary to live in the community
• Impaired judgment (including social
boundaries)
• Inability to self-protect in community
situations
• Inability to safely self-medicate or self-
manage illness
• Aggression
• Inability to access community resources
necessary for safety
• Impaired community living skills
Please provide additional information (justification) for #6. DO NOT CIRCLE
AND/OR CHECK OFF ANY ITEMS IN #6.
Revised: BHA\AdultServices\RRPapp\09\01\17
7
8
K. Specialized Services: Please indicate whether or not the specialized service is necessary for the applicant to live in
the Residential Rehabilitation Program.
L. Additional Comments: (Please state additional information that was not specified in the application):
If applicant requires additional services that are beyond the scope of what is provided in the Intensive RRP bed, pleas
e explain what
services are needed. This section can also be used for additional comments about the RRP applicant as needed by the referral source.
Referral Source Name (Please Print): _____________________________________ Date Signed: ______ / ______ / ______
Referral Source Signature: _____________________________________
Specialty Service
(Not provided by all RRP providers – See instruction sheet for specific jurisdiction)
Please check your response
ITCOD (Integrated Treatment for Co
-
Occurring Disorders)
(Integrated Treatment for Co-Occurring Disorders (ITCOD) model is an evidence-based practice that
improves the quality of life for people with co-occurring severe mental illness and substance use disorders
by combining substance use services with mental health services. It helps people address both disorders
at the same time—in the same service organization by the same team of treatment providers.)
Yes No
TAY
(Transitional Age Youth)
(“Transition age youth” are defined as individuals between the ages of 16 and 25 years that require
comprehensive support services to transition these individuals into adulthood with proper services and
supports uniquely tailored to this age group.)
Yes No
DD/MH
(Developmental Disability/Mental Health
(Has a developmental disability as defined by the Developmental Disabilities Assistance and Bill of Rights
Act of 2000-Public Law 106-402 and also has a psychiatric disorder as defined by DSM-5)
Yes No
DEAF
(Deaf or Hard of Hearing and/or require the services of American Sign Language interpreters/counselors to
assist the consumer to live in the community.)
Yes No
GERIATRIC
(Elderly applicants whose behaviors may be psychiatric in nature that require the services in order to
manage the mental illness and the treatment is appropriate to meet their needs. Collaboration and
communication with physical medicine and geriatric medicine is necessary for purposes of ongoing
management of the behaviors.)
Yes No
Revised: BHA\AdultServices\RRPapp\09\01\17
RESIDENTIAL REHABILITATION PROGRAM
CONSENT FOR RELEASE OF INFORMATION
I, ______________________________________, give my consent for _______________________________________
(Applicant’s Name) (Core Service Agency)
and any other Core Service Agency checked by the applicant to release this application and other clinical and/or
psycho-social history to a Residential Rehabilitation Program for the purpose of assessing my eligibility for residential
services in the community. I understand that this information will not be released to another party without my written
consent.
I understand this application does not guarantee an interview with a potential Residential Rehabilitation Program and does
not commit the Core Service Agency (CSA) to provide a residential placement.
OUT-OF-COUNTY RRP PLACEMENT(S) ONLY
:
I give my consent to the Core Service Agency to release my application and/or mental health information to the Core
Service Agency (ies) that I have selected below. The applicant is requesting an out-of-county placement for the following
reasons: (a) requests to live in a particular jurisdiction; (b) wishes to be near his/her family; (c) the current RRP agencies
in the CSA jurisdiction are at capacity and not in a position to expand services; (d) the current RRP agencies in the CSA
jurisdiction lack special programming to meet specific needs (for example, TAY, Deaf, etc.). It is understood that the
Core Service Agency (ies) will give high priority to its own in-county residents and my application will not supersede an
in-county resident (unless my application was submitted by a state psychiatric hospital provider due to high priority
status for placement as mandated by the MD Behavioral Health Administration). If the applicant is requesting an out-
of-county placement, please select no more than three (3) jurisdictions for submission of the application to the Core
Service Agency in the requested county(ies) and the applicant must be willing to live in that jurisdiction.
Allegany
Carroll
Harford
Somerset
Anne Arundel
Cecil
Howard
St. Mary's
Baltimore City
Charles
Mid-Shore (Caroline, Dorchester, Kent,
Queen Anne’s, Talbot Counties)
Washington
Baltimore County
Frederick
Montgomery
Worcester
Calvert
Garrett
Prince George’s
This consent form will be valid for and will expire in twelve (12) months from my signature date as indicated
below. I understand that I will need to submit a new application every twelve (12) months.
_____________________________________ _______________
(Applicant’s Signature) (Date)
_____________________________________
(Print Applicant’s Name)
_____________________________________ _______________
(Witness’s Signature) (Date)
_____________________________________
(Print Witness’s Name)
****************************************************************************************
If the applicant does not have the legal authority to sign the consent form, the referral source must secure the signature of the
person and/or agency representative who currently has the legal authority to provide consent for the submission of the Residential
Rehabilitation Program application. Please attach proof of the person’s legal authority for the applicant.
Person’s Signature: _______________________________
________ Date: __________________
Print Person’s Name: _______________________________________
Person’s Title (if applicable): _______
________________________________
Person’s Telephone #: ________________________
_______________
Agency Name (if applicable): _______________________________________
Revised: BHA\AdultServices\RRPapp\09\01\17
9
click to sign
signature
click to edit
click to sign
signature
click to edit
Attachment #1:
APPLICANT’S NAME: ________________________________ DATE OF BIRTH: ____________
LIST OF CURRENT MEDICATIONS
NAME OF
MEDICATION
DOSAGE
FREQUENCY
ADMINISTRATION
(oral, IM, topical)
PRESCRIBER’S
NAME
Revised: BHA\AdultServices\RRPapp\09\01\17
10
Attachment #2
Priority Population Diagnoses – Adults
Please use the Priority Population Diagnoses listed below as the primary diagnosis (es) for the
applicant.
DSM-5 Diagnosis ICD-10
CODE
Schizophrenia
F20.9
Schizophreniform Disorder
F20.81
Schizoaffective Disorder, Bipolar Type
F25.0
Schizoaffective Disorder, Depressive Type
F25.1
Other Specified Schi
zophrenia Spectrum and Other Psychotic Disorder
F28
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
F29
Delusional Disorder
F22
Major Depressive Disorder, Recurrent Episode, Severe
F33.2
Major Depressive Disorder, Recurrent Episode, With Psychotic
Features
F33.3
Bipolar
I Disorder, Current or Most Recent Episode, Manic, Severe
F31.13
Bipolar I Disorder, Current or Most Recent Episode, Manic, With Psychotic Features
F31.2
Bipolar I Disorder, Current or Most Recent Episode
,
Depressed, Severe
F31.4
Bipolar I Disorder, Current or Mo
st Recent Episode, Depressed, With Psychotic Features
F31.5
Bipolar I Disorder, Current or Most Recent Episode, Hypomanic
F31.0
Bipolar I Disorder, Current or Most Recent Episode, Hypomanic, Unspecified
F31.9
Unspecified Bipolar and Related Disorder
F31.9
Bipolar II Disorder
F31.81
Schizotypal Personality Disorder
F21
Borderline Personality Disorder
F60.3
T
he diagnostic criteria may be waived for either one of the
following two conditions:
1. An individual committed as not criminally responsible who is conditionally released
from a Mental Hygiene facility, according to the provisions of Health General Article, Title
12, Annotated Code of Maryland.
Please check if applicable:
2. An individual in a Mental Hygiene facility with a length of stay of more than 6 months
who requires RRP services.
This excludes individuals eligible for Developmental
Disabilities services.
Please check if applicable:
Revised: BHA\AdultServices\RRPapp\09\01\17
11
Substance Use Disorders
Please use the Substance Use Disorders if the applicant has a co-occurring disorder. This should
not be the primary diagnosis. The primary diagnosis must be one or more of the Priority
Population diagnoses listed above.
Substance Use Disorders
ICD-10 CODE
Alcohol Use Disorder – Mild
F10.10
Alcohol Use Disorder – Moderate
F10.20
Alcohol Use Disorder – Severe
F10.20
Cannabis Use Disorder – Mild
F12.10
Cannabis Use Disorder – Moderate
F12.20
Cannabis Use Disorder – Severe
F12.20
Opioid Use Disorder – Mild
F11.10
Opioid Use Disorder – Moderate
F11.20
Opioid Use Disorder – Severe
F11.20
Stimulant-Related Disorder – Cocaine – Mild
F14.10
Stimulant-Related Disorder – Cocaine – Moderate
F14.20
Stimulant-Related Disorder – Cocaine – Severe
F14.20
Stimulant-Related Disorder – Amphetamine-type substance – Mild
F15.10
Stimulant-Related Disorder – Amphetamine-type substance – Moderate
F15.20
Stimulant-Related Disorder – Amphetamine-type substance – Severe
F15.20
Tobacco Use Disorder – Mild
Z72.0
Tobacco Use Disorder – Moderate
F17.200
Tobacco Use Disorder – Severe
F17.200
Other (or Unknown) Substance Use Disorder – Mild
F19.10
Other (or Unknown) Substance Use Disorder – Moderate
F19.20
Other (or Unknown) Substance Use Disorder – Severe
F10.20
Revised: BHA\AdultServices\RRPapp\09\01\17
12
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RESIDENTIAL REHABILITATION PROGRAM APPLICATION FORM INSTRUCTIONS (Prince George's CountyOffice of Information Technology and Communications)

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Completed 18 July 2020

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