Referrals

Service Referral

To be accepted into the program, a person must meet the following requirements:

1) Individuals requiring Mental Health Services (Psychiatric Evaluation, Psycho-Social Assessment, Psychotherapy, or Medication management) may call the office to book an appointment or visit the agency’s website to make a booking.

2) To be accepted into the PRP program, a person must meet the following requirements:

Have a Mental Health Diagnosis,

Be referred by the treating Therapist or a Licensed Provider (Psychiatrist, Psychiatric Nurse, LCSW-C, LCPC, etc.),

Submit the completed referral form and your most recent Psychiatric or Psycho -evaluation,

Complete a formal intake & admission process.

3) Referrals for services will be accepted from Individuals seeking services, families, and other mental health service providers.
Referrals can be sent:

Via our website: www.care-connect.us

By Email: info@care-connect.us

By Fax to - 410-254-3005

Called By Telephone: 410-254-3002

4) Service Population:

For Mental Health Services: Anyone requiring services will be accepted into the program upon completing our referral and admission process.

For Psychiatric Rehabilitation Program (PRP) Services: Children, Adolescents & Adults with mental health diagnoses will be accepted into the program upon completion of our referral and admission process.

5) Service Payment Methods:

We currently accept: Maryland Medicaid & Private (Self) Pay.

Referral Intake Form

Referring Therapist *

License *

Referring Source

Phone Number *

Fax

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Service Referred for (Check all that apply)

PRP for Adult
Rehabilitation Assessment
PRP for Children & Adolescent
Individual Rehabilitation Plan

Others

Client Information

Last Name, First Name *

First

Last

Date of Birth

Social Security Number

MA#

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Sex

Male
Female

Employment

Height

Weight

Eye Color

Hair Color

Phone Number

Living Situations

Emergency Contact Name

Relationship

Contact Phone

Best Time to call

Medical/medications concerns

Mental Health Diagnoses

Other Information

Name of Previous Provider (If any)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Current School Placement/School Grade

Contact Person

Phone Number

Special Education Services(describe)

Reason(s) for Referral

(Brief Description of the complaint & history of presenting problem, including precipitating factors and history of substance abuse)

What are the risk indicators: (e.g: out of home placement, truancy, decompensation)

Referrals

Referrals

Service Referral

1) Individuals requiring Mental Health Services (Psychiatric Evaluation, Psycho-Social Assessment, Psychotherapy, or Medication management) may call the office to book an appointment or visit the agency’s website to make a booking.

2) To be accepted into the PRP program, a person must meet the following requirements:

3) Referrals for services will be accepted from Individuals seeking services, families, and other mental health service providers. Referrals can be sent:

4) Service Population:

5) Service Payment Methods:

Referral Intake Form

Referral Intake Form

Client Information

Other Information

Reason(s) for Referral

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3) Referrals for services will be accepted from Individuals seeking services, families, and other mental health service providers.
Referrals can be sent: