Referral form 1 of 2

PRP referral form

For treating mental health providers referring a client into our Psychiatric Rehabilitation Program. Submissions go straight to our intake team.

Before you start

Have these ready

  • Signed provider certification (within the last 12 months)
  • Most recent psychiatric evaluation
  • Current medication list and prescriber contact
  • Active insurance or Medicaid information

Attach supporting documentation to the email that opens after you submit. All contact and follow-up is handled by email.

Basic information

PRP eligibility – ICD-10 diagnoses

Eligibility is restricted to the diagnoses below for adults (minors may have any diagnosis). Check all that qualify.

Reason for PRP referral

Therapist / agency info

Sends securely to info@jeichealthcare.com