PRP Forms

For Licensed Mental Health Professionals: Use the forms below to refer an individual to the BHLD Psychiatric Rehabilitation Program

Securely handle Private HIPAA Information! We have made it easy. Save your form to your PC then use Adobe Reader DC to fill out and Digitally Sign, then email it to BHLD PRP Services using our encrypted, secure email address contact@secure.bhcld.com

BHLD PRP Referral – Adult Form

Use this form to refer an adult age 18-70 to BHLD Psychiatric Rehabilitation Program.

Save your document to your PC and use Adobe PDF Reader to open it before you start in order to sign it digitally.

BHLD PRP Referral – Minor Form

Use this form to refer a minor age 5-17 to BHLD Psychiatric Rehabilitation Program.

Save your document to your PC and use Adobe PDF Reader to open it before you start in order to sign it digitally.

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These files are in Adobe PDF format. If you do not have Adobe Reader on your computer, you can download it for free by clicking here or on the Adobe Reader icon.

If you prefer to FAX

Print entire document SIGN, CREDENTIAL, and DATE printed form and FAX TO: 410-630-1021