Referral

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  • Social Security #Medical Assistance # 
  • School/Grade (if applicable)Address 
  • *SOCIAL SECURITY NUMBER MUST BE KNOWN TO PROCESS REFERRAL*
  • REFERRAL INFORMATION

  • NameAgency (if applicable) 
  • Phone NumberEmail Address 
  • PARENT/GUARDIAN INFORMATION:

  • NameRelationship 
  • AddressContact Number 
  • *A LEGAL DOCUMENT MUST BE PRESENTED TO SHOW GUARDIANSHIP*
  • PLEASE ANSWER THE FOLLOWING INFORMATION:

  • 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.

Got a Question?
Ask us here.

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.

Our Contact Information:

Hours of Operation:

Due to COVID-19, we will not be accepting walk-in appointments.

We will be holding our appointments via Zoom.

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

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