Referral Form

Referral Form
Are you completing this form for yourself or another person?

Client Information

Preferred contact method (By submitting this contact form you consent to being contacted, which includes our company information.)
Please Note: We ask for insurance purposes
Pronouns (Select all that apply)
Race/Ethnicity (Select all that apply)
Please note that we ask this question to assure quality care for all.
Are you a licensed clinician and able to provide a qualifying diagnosis?

Expanded Client Information

Why are you referring your client to Maryland Wellness? (Select all that apply)
Is the client an adult or minor (under 18)?
Please check all qualifying diagnoses (select all that apply)
If psychosis noted as DX:

Minor Client Information

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

Adult Client Information

Providers must select a minimum of 3 out of the 7 following questions.
e.g. Client suffers from bipolar II disorder with extreme emotional fluctuation which causes conflict within the workplace.
e.g. Client has major depression (recurrent) and lacks motivation and avoids completing basic tasks such as laundry, housekeeping, meal preparation.
e.g. Client has borderline personality disorder and can be volatile around personal support system which they push away.
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.
e.g. Client’s major depression causes them to feel unmotivated, leading to trouble completing basic hygiene like dental hygiene, showering, changing of clothes.
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.
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.

Your Information

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– D.J., Baltimore
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“Maryland Wellness is great!!! The staff really helped me and my daughter get settled into our new home and school. I’m a single mother and I struggled with transportation and housing. With the help of my counselor, I was able to get to my destinations and became stress free about my housing!”
– T.D., Waldorf

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