Date: Dear Mental Health Professional,

Date: Dear Mental Health Professional, Attached is the Referral Form required to receive PRP services from Mosaic Community Services. The following is required to complete the application process: Completed Referral Form Medical Records providing a psychosocial and diagnostic summary Results of a physical completed within the last year (Physical Form attached if needed) Please fax the above information to my attention at (443) 612-1425. Upon its receipt, I will contact you to schedule an intake appointment. Please feel free to contact me at 410-453-9553 x 1207 with any questions. I look forward to working with you. Sincerely, Mosaic Community Services Intake Coordinator

Mosaic Community Services PRP Referral Form Referral Source Information: Referral Source Name Phone Number: Referral Source Agency Referral Date: GENERAL INFORMATION: Full Name Address Date of birth SSN Phone Number Emergency Contact Name Relationship Address Home number Work number Does this client have a guardian of person or property? NO Yes (please provide info) Marital Status ( ) Married ( ) Divorced ( ) Separated ( ) Never Married ( ) Widowed Number of children Do the children live with the client ( ) Yes ( ) No Support system Residential Arrangement: ( ) Care Provider ( ) With Relative(s) ( ) Homeless/Shelter ( ) Group Home ( ) Lives Alone in community ( ) Other Is client employed? ( )Yes ( ) No If yes ( ) Full-time ( ) Part-time Place of Employment Phone number INSURANCE / FINANCIAL INFORMATION Medical Assistance Number If the client does not have Medical Assistance what was the date of application Medicare Number Other Insurance ( ) Yes ( ) No If yes, name of insurance carrier Monthly Income Source of income LEGAL HISTORY: Has the client been arrested? ( ) Yes ( ) No List any convictions Is client on probation? ( )Yes ( ) N Parole? ( ) Yes ( ) No Found NCR? ( ) Yes ( ) No Probation/Parole officer s name Contact Number

CLINICAL INFORMATION: Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Date: Code Code Code Significant Medical Problems/Allergies: Current Medications including dosage and frequency: Medication compliance history Total number of hospitalizations Date and location of most recent hospitalization Reason for admission History of violence (please explain) Any known Risk Taking Behavior? (i.e. recent suicide attempt, etc.) Please specify the clinical symptoms that indicate the need for Mosaic s PRP services: SUBSTANCE ABUSE HISTORY: Substance Duration of Use/ Frequency of Use Does client attend ( ) NA or ( ) AA? Location Freq. Has client received inpatient or outpatient substance abuse treatment? ( ) Yes ( ) No If yes, date and location:

TREATMENT PROVIDERS: Primary Care Physician Contact Number Organization Address Psychiatrist and/ or Therapist Contact Number Organization Address Already a client at Mosaic? Location of Clinic: Psychiatrist: Therapist: Service Coordinator: Phone No. PRP Services New Ventures PRP Hall 1931 Greenspring Drive 20 Winters Lane 288 East Greene Street Timonium, MD 21093 Catonsville, MD 21228 Westminster, MD. 21157 North Charles Street I am interested in: Day program In Home Support Services Vocational Services 1925 Greenspring Drive 5 Bloomsbury Avenue 288 East Green Street Timonium, MD 21093 Catonsville, MD 21228 Westminster, MD 21157 North Charles Street I am interested in: Supported Employment Services Career Center Transportation Services If transportation is required, please complete the attached Transportation Application form and include with the referral packet. Please keep in mind that transportation services cannot be guaranteed. Somatic Care Services (Grant) Please refer to Division Director of Medical Services (410) 453-9553 ext. 1212 Somatic Care Grant 2225 N. Charles Street Fourth Floor Baltimore, MD 21218

Psychiatric Rehabilitation Program Mental Health Professional Form Mental Hygiene Administration requires all PRP providers to obtain a referral from a mental health professional at the time of referral, and then every 6 months thereafter. I am referring to Mosaic Community Services Psychiatric Rehabilitation Program (PRP) for assessment and continued on site and/or off site psychiatric rehabilitation services and crisis managment. This service is medically necessary to facilitate the client s wellness and recovery. Comments (Optional): Signature and Title/Licensure of Mental Health Professional Date Clinician Name Printed Attempts to obtain this referral were made on the following dates by (ex. fax, hand delivery, client delivery)*: / / by / / by *attach fax receipts and any other documents supporting the effort made to obtain referral. Dev: 8/09, Rev: 3/10, 4/10

Appendix C Priority Population Adults SEVERELY MENTALLY ILL PRIORITY POPULATION DEFINITION - ADULTS (SMI) Revised 9/1/03, 3/10/14 Reviewed 05/10/07, 1/25/10 INCLUDED DIAGNOSES (DSM-5 including ICD-9 and ICD-10 diagnosis codes): 295.90/F20.9 Schizophrenia 295.40/F20.81 Schizophreniform Disorder 295.70/F25.0 Schizoaffective Disorder, Bipolar Type 295.70/F25.1 Schizoaffective Disorder, Depressive Type 298.8/F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder 298.9/F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder 297.1/F22 Delusional Disorder 296.33/F33.2 Major Depressive Disorder, Recurrent Episode, Severe 296.34/F33.3 Major Depressive Disorder, Recurrent Episode, With Psychotic Features 296.43/F31.13 Bipolar I Disorder, Current or Most Recent Episode Manic, Severe 296.44/F31.2 Bipolar I Disorder, Current or Most Recent Episode Manic, With Psychotic Features 296.53/F31.4 Bipolar I Disorder, Current or Most Recent Episode Depressed, Severe 296.54/F31.5 Bipolar I Disorder, Most Recent Episode Depressed, With Psychotic Features 296.40/F31.0 Bipolar I Disorder, Current or Most Recent Episode Hypomanic 296.40/F31.9 Bipolar I Disorder, Current or Most Recent Episode Hypomanic, Unspecified 296.7/F31.9 Bipolar I Disorder, Unspecified 296.89/F31.81 Bipolar II Disorder 301.22/F21 Schizotypal Personality Disorder 301.83/F60.3 Borderline Personality Disorder INCLUDED DIAGNOSES (DSM-IV): 295.10 Schizophrenia, Disorganized Type 295.20 Schizophrenia, Catatonic Type 295.30 Schizophrenia, Paranoid Type 295.40 Schizophreniform Disorder 295.60 Schizophrenia, Residual Type 295.70 Schizoaffective Disorder 295.90 Schizophrenia, Undifferentiated Type (*includes ICD-9 diagnoses 295.10-295.95)

296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic Features 296.34 Major Depressive Disorder, Recurrent, Severe With Psychotic Features 297.1 Delusional Disorder 298.9 Psychotic Disorder, NOS 301.22 Schizotypal Personality Disorder 301.83 Borderline Personality Disorder 296.43 Bipolar I Disorder, Most Recent Episode, Manic, Severe Without Psychotic Features 296.44 Bipolar I Disorder, Most Recent Episode, Manic, Severe With Psychotic Features 296.53 Bipolar I Disorder, Most Recent Episode, Depressed, Severe Without Psychotic Features 296.54 Bipolar I Disorder, Most Recent Episode, Depressed, Severe With Psychotic Features 296.63 Bipolar I Disorder, Most Recent Episode, Mixed, Severe Without Psychotic Features 296.64 Bipolar I Disorder, Most Recent Episode, Mixed, Severe With Psychotic Features 296.80 Bipolar Disorder, NOS 296.89 Bipolar II Disorder -and- In order to be included in the PRIORITY POPULATION, individuals must meet the target diagnostic criteria and meet the following functional limitations: Serious mental illness is characterized by impaired role functioning, on a continuing or intermittent basis, for at least two years, including at least three of the following: Inability to maintain independent employment, Social behavior that results in interventions by the mental health system, Inability, due to cognitive disorganization, to procure financial assistance to support living in the community, Severe inability to establish or maintain a personal support system, or Need for assistance with basic living skills. The diagnostic criteria may be waived for the following two conditions: 1. An individual committed as not criminally responsible who is conditionally released from a Mental Hygiene Administration facility, according to the provisions of Health General Article, Title 12, Annotated Code of Maryland. Or 2. An individual in a Mental Hygiene Administration facility with a length of stay of more than 6 months who requires RRP services, but who does not have a target diagnosis. This excludes individuals eligible for Developmental Disabilities services.