Referral

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Returning Customer?

Yes

No

Today's Date

Consumer Name

Date of Birth

identity Confirnation

Social Security #

Medical Assistance #

Gender*

Male

Female

Phone*

identity Confirnation

School/Grade (if applicable)

Address

*SOCIAL SECURITY NUMBER MUST BE KNOWN TO PROCESS REFERRAL*

REFERRAL INFORMATION

Name

Agency (if applicable)

extra information

Phone Number

Email Address

PARENT/GUARDIAN INFORMATION:

name and relationship

Name

Relationship

extra information

Address

Contact Number

*A LEGAL DOCUMENT MUST BE PRESENTED TO SHOW GUARDIANSHIP*

PLEASE ANSWER THE FOLLOWING INFORMATION:

Is the consumer of Hispanic, Latino, or Spanish origin?:

Race

How well does the consumer speak English?

Does the consumer speak another language other than English at home?

If Yes, what is the language?

Number of arrest in the past 30 days?

Is the consumer deaf or do they have hearing difficulty?

Is the consumer blind or do they have serious difficulty seeing, even when they wear glasses?

REASON FOR REFERRAL:

In your own words, describe the child/adult in need for therapy services. Please describe any behaviors the child/adult is exhibiting. Please specifically note any of the following whether current or a history of: Recent Hospitalizations, Suicide Attempts or Ideation, Self‐harm, Violence towards others, Aggression, Domestic Violence, Psychotic Symptoms, Substance Abuse, Behavior Problems, & Mood Related Symptoms.

Signature*

Today's Date*

Prove you are human

Phone

This field is for validation purposes and should be left unchanged.

Got a Question? Ask us here.

"(Required)" indicates required fields

Name(Required)

First Last

Best Phone(Required)

Best Email(Required)

What type of inquiry is it?(Required)

What's on your mind?(Required)

Prove you are human

Phone

This field is for validation purposes and should be left unchanged.

Our Contact Information:

Hours of Operation:
Monday-Friday: 10am-6pm
Saturday: By appointment only

Ph: 1(800) 605-6949
Fax: 301 577 1489

Address:
13 C Street, Suite B, Laurel, MD 20707

Got a Question? Ask us here.

"(Required)" indicates required fields

Name(Required)

First Last

Best Phone(Required)

Best Email(Required)

What type of inquiry is it?(Required)

What's on your mind?(Required)

Prove you are human

Phone

This field is for validation purposes and should be left unchanged.

Our Contact Information:

Ph: 1(800) 605-6949
Fax: 301 577 1489

Locations:

400 W. Saratoga Street Baltimore MD 21201

Hours of operation:

Monday – Friday 9am – 5pm
Saturday - Closed
Sunday (Closed)

Phone Number: 410 438 4505
Toll Free Number: 1800 605 6949
Fax: 410-881-8012

13 C Street, Suite B, Laurel, MD 20707

Hours: By appointment only

Phone 1800-605-6949
Fax Number 301 339 4648