BEHAVIORAL HEALTH ADMINISTRATION RESIDENTIAL

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MDH #4812 (August 1, 2018)

BEHAVIORAL HEALTH ADMINISTRATION

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 Core Service Agency\Local Behavioral Health Authority 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\LBHA 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)

Wicomico

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\Local Behavioral Health Authority).

• Questi

ons regarding program vacancies should be directed to the Core Service Agency\Local Behavioral Health Authority.

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MDH #4812 (August 1, 2018)

• Please submit only pages 3-10 to the Core Service Agency\Local Behavioral Health Authority. Discard pages 1-2 and pages 11-12

(these pages are not necessary and are not required by the Core Service Agency\Local Behavioral Health Authority).

• The application must be sent to the Core Service Agency\Local Behavioral Health Authority 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\Local

Behavioral Health Authority address (mail) or the Core Service Agency\Local Behavioral Health Authority fax number (fax). Please

mark the envelope or fax cover sheet: Attn: Adult Services Coordinator or Residential Specialist.

CORE SERVICE AGENCIES\LOCAL BEHAVIORAL HEALTH AUTHORITIES:

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

100 S. Charles Street, Tower 2, 8

Floor

Baltimore, Maryland 21201

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 Health Dept.\Bureau of Behavioral Health

8930 Stanford Boulevard

Columbia, Maryland 21045

Phone: 410-313-6202 Fax: 410-313-6212

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 Authority

9314 Piscataway Road

Clinton, Maryland 20735

Phone: 301-856-9500 Fax: 301-856-9558

SOMERSET COUNTY

Somerset County Core Service Agency

Somerset County Health Department

7920 Crisfield Highway

Westover, Maryland 21871

Phone: 443-523-1

786 Fax: 410-651-3189

ST. MARY’S COUNTY

St. Mary's County Local Behavioral Health Authority

21580 Peabody Street

P.O. Box 316

Leonardtown, Maryland 20650

Phone: 301-475-4330 Fax: 301-363-0312

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

WORCESTER COUNTY

Worcester County Core Service Agency

P.O. Box 249

Snow Hill, Maryland 21863

Phone: 410-632-3366 Fax: 410-632-0065

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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

Frederick

Mid-Shore (Caroline, Dorchester, Kent,

Queen Anne’s, Talbot Counties)

St. Mary’s

Anne Arundel

Carroll

Garrett

Montgomery

Washington

Baltimore City

Cecil

Harford

Prince George’s

Wicomico

Baltimore County

Charles

Howard

Somerset

Worcester

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: ____________________________

bile: ____________________________

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

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: ________________________

___________________________________________

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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 #1: 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: ___________________________________________________________

___________________________________________________________

her Conditions that may be a Focus of Clinical Attention:

___________________________________________________________

__________________

D. Substance Use Information:

Substance Use History

Previous history of drug use

(including alcohol)

Date(s) Used

Amount

How Used (Smoked, IV, etc.)

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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 Circuit 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)

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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 Level 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 Necessity 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 Level. Unacceptable responses include: Yes, No, Cannot, Maybe, etc.

GENERAL level: Please complete items 1 - 5 of the Admission Criteria

INTENSIVE level: 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 PBHS 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):

ease provide additional information 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

Please provide additional information (justification) for #3:

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needed as evidenced for example, by one of the

following:

• 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.

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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, please explain what

services are needed. This section can also be used for additional comments about the RRP applicant as needed by the referral source.

Ref

erral 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 abuse 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

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RESIDE

NTIAL REHABILITATION PROGRAM

CONSENT FOR RELEASE OF INFORMATION

I, ______________________________________, give my consent for _______________________________________

(Applicant’s Name) (Core Service Agency/Local Behavioral Health Authority)

and any other Core Service Agency\Local Behavioral Health Authority 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 unders

tand this application does not guarantee an interview with a potential Residential Rehabilitation Program and does

not commit the Core Service Agency (CSA)\Local Behavioral Health Authority (LBHA) to provide a residential

placement.

OUT-OF-COUNTY RRP PLACEMENT(S) ONLY:

I give my consent to the CSA\LBHA to release my application and/or mental health information to the CSAs\LBHAs 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\LBHA

jurisdiction are at capacity and not in a position to expand services; (d) the current RRP agencies in the CSA\LBHA

jurisdiction lack special programming to meet specific needs (for example, TAY, Deaf, etc.). It is understood that the

CSAs\LBHAs 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 CSA\LBHA 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)

Washington

Baltimore County

Frederick

Montgomery

Wicomico

Calvert

Garrett

Prince George’s

Worcester

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.

Perso

n’s Signature: _______________________________________ Date: __________________

Print Person’s Name: _______________________________________

Pers

on’s Title (if applicable): _______________________________________

Perso

n’s Telephone #: _______________________________________

Agency Name (if applicable): _______________________________________

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Attachment #1:

APPLICANT’S NAME: ________________________________ DATE OF BIRTH: ____________

LIST OF CURRENT MEDICATIONS

NAME OF

MEDICATION

DOSAGE

FREQUENCY

ADMINISTRATION

(oral, IM, topical)

PRESCRIBER’S

NAME

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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 Schizophrenia 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 Most 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

The 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:

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Sub

stance 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