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COMMUNITY THERAOEUTIC CENTER, INC.

Psychiatric Rehabilitation Program (PRP)

www.communitytherapeutic.com

Please complete form in its entirety; contact our office with any questions.
Child/Adolescent Adult
Male Female Transgender
Phone
Yes No
Yes No

LEGAL GUARDIAN/CAREGIVER

Contact Information (if different from above)

CURRENT CLINICIAN/PSYCHIATRIST

Dianosis (please include secondary if applicable)
Yes No
Yes No
Yes No

REASON for REFERRAL

Select specific area(s) of need below.
Personal hygiene
Nutrition
Physical activity
Personal safety
Developing supports
Conflict resolution
Boundary awareness
Interactive skills
Money management
Maintaining living environment
Cooking/Shopping
Time management
Identifying resources
Entitlements
Housing
Vocational
Anger
Anxiety
Grief and loss
Other

REFERRED BY

10104 SENATE DR, #222, LANHAM, MD 20706
Office: 240-764-5133       Fax: 240-764-8897
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