The Referral Form for Maryland Wellness Outpatient Mental Health

Date

Are you completing this form for yourself or another person?

I am completing this for myself

I am completing this form for another person

Client Information

First Name

Middle Initial

Last Name

Birthdate

Parent/Guardian Name

Parent/Guardian Contact Information

Address

Homeless

City

State

ZIP

Phone

Email Address

Preferred contact method (By submitting this contact form you consent to being contacted, which includes our company information.)

Phone

Text

Email

Sex Sex

Please Note: We ask for insurance purposes

Gender Identity Gender Identity

Pronouns (Select all that apply)

Insurance Provider Insurance Provider

What are you seeking help with?

How did you hear about us? How did you hear about us?

Physician Name

Mental Health Provider Name

Community Resource/Service Name

Current Client Name

Friend/Family

Event Name

Maryland Wellness Team Member

Have you previously worked with Maryland Wellness, Baltimore Area Community Health Services (BACHS), Alek’s House, Aspen Wellness Center or Bridging Gaps with New Beginnings?

Are you a licensed clinician and able to provide a qualifying diagnosis?

Yes

No

Expanded Client Information

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Email

Client's Insurance #

Medicaid

Why are you referring your client to Maryland Wellness? (Select all that apply)

Is the client an adult or minor (under 18)?

Adult

Minor (under 18)

If psychosis noted as DX:

Auditory

Visual

Please provide the ICD 10 Diagnosis(es) and description below (please note that Autism is not a covered DX):

Within the past three months, the individual's emotional disturbance has resulted in:

Minor Client Information

Providers must answer 2 of the first 3 Functional Criteria questions. Questions 4 and 5 are required.

1. What is the clear, current threat to the youth's ability to be maintained in their customary setting? Please describe a current threat:

e.g. the minor cannot be maintained in a classroom setting due to anger outbursts, frustration, and verbal and/or physical aggression towards teachers and/or peers

2. Is the minor an emerging risk to the safety of the youth or others? Please describe the emerging risk to safety:

e.g. the minor engages in self-harm behavior such as cutting and has acted aggressively towards family members as well as destructive in home environment

3. Significant psychological or social impairments causing serious problems with peer relationships and/or family members?

Yes

No

Please describe the psychological or social impairments:

e.g. the minor avoids social interactions and cancels plans frequently with peers and family due to anxiety caused when around others; minor is frequetly isolated which worsens distress. Frequent tantrumming has made it difficult for family members to discipline and assist minor with better choices.

4. How long has the youth been in documented outpatient therapy for, has any attempt been made to increase the frequency, and has medication been considered/offered?

e.g. minor continues to make reckless and impulsive decisions at school and in the community which have negative impact on minor, such as school suspensions, and problems with authority figures despite participation in therapy. Minor could benefit from more time and more direct assistance.

5. Has the youth made progress toward age appropriate development, more individual functioning and independent living skills?

e.g. minor is making some progress; with consistent prompting when situations allow, minor has been able to better manage anger, and self calm and decrease explosive behavioral outbursts however this is not yet consistent.

Yes

No

Please describe the improvements:

What improvements are being made to help make progress?

What is the clinical rationale for referring this client to PRP services? (focus on diagnosis not client needs, i.e. bus pass)

Adult Client Information

Providers must select a minimum of 3 out of the 7 following questions.

1. Does the client struggle with obtaining/maintaining employment? Please indicate what is the diagnosis, what symptoms affect the client based on the DX and how do those symptoms hinder the client in that area.

e.g. Client suffers from bipolar II disorder with extreme emotional fluctuation which causes conflict within the workplace.

2. Does the participant have marked inability to perform instrumental activities of daily living? Please indicate what is the diagnosis, what symptoms affect the client based on the DX and how do those symptoms hinder the client in that area.

e.g. Client has major depression (recurrent) and lacks motivation and avoids completing basic tasks such as laundry, housekeeping, meal preparation.

3. What is the participant’s marked inability to establish/maintain a personal support system? Please indicate what is the diagnosis, what symptoms affect the client based on the DX and how do those symptoms hinder the client in that area

e.g. Client has borderline personality disorder and can be volatile around personal support system which they push away.

4. What are the participant’s deficiencies of concentration/ persistence/pace leading to failure to complete tasks? Please indicate what is the diagnosis, what symptoms affect the client based on the DX and how do those symptoms hinder the client in that area

e.g. Client contends with bipolar I disorder. Mania episodes lead to anger outbursts and getting frustrated easily which results in them them failing to complete tasks.

5. Is the participant unable to perform self-care? Please indicate what is the diagnosis, what symptoms affect the client based on the DX and how do those symptoms hinder the client in that area

e.g. Client’s major depression causes them to feel unmotivated, leading to trouble completing basic hygiene like dental hygiene, showering, changing of clothes.

6. What are the participant’s marked deficiencies in self-direction, shown by inability to plan, initiate, organize and carry out goal directed activities? Please indicate what is the diagnosis, what symptoms affect the client based on the DX and how do those symptoms hinder the client in that area

e.g. Client’s bipolar and frequent mood fluctuations that make it difficult to start and finish tasks, recall and follow multi-step directions and because of frustration, often give up on tasks.

7. What is the participant’s marked inability to procure financial assistance to support community living? Please indicate what is the diagnosis, what symptoms affect the client based on the DX and how do those symptoms hinder the client in that area

e.g. Client has schizoaffective disorder leading to disorganized thinking and behavior, which limits access to resources particularly financial support as they often have trouble understanding forms and rules related to the assistance requested.

What is the clinical rationale for referring this client to PRP services? (focus on diagnosis not client needs, i.e. bus pass)

Your Information

Your First Name

Your Last Name

Your Title and Credentials

If applicable, do you intend to remain the treating therapist?

If LMSW or LGPC, Your Supervisor's Name and Credentials

Your Agency/Organization

Address

City

State

ZIP

Your Email Address

Your Phone Number

Additional Notes

Signature

Clear

Date

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Identification (ID)

Maximum file size: 52.43MB

Insurance Card - Front

Maximum file size: 52.43MB

Insurance Card - Back

Maximum file size: 52.43MB

Medication List

Maximum file size: 52.43MB

Other Healthcare Paperwork (Hospital Discharge, Medical Records, etc.)

Maximum file size: 52.43MB

Referral Form

Client Information

Expanded Client Information

Minor Client Information

Adult Client Information

Your Information

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