Online Therapy and Medication Referral Form

Every question with a * is required.

Client First name

Client Last name

Address

Does the Client have a legal guardian?

Yes

No

Name of Parent or Guardian

Relation to client

Phone

Email (18 and up or Parent or Guardian)

Client's SSN

Client's DOB

Month

Day

Year

Maryland Medicaid/Medical Assistance

Yes

No

Are they current enrolled in MTS/ACT, Targeted Case Management, Mental health Residential Treatment Center, Residential Substance Use Disorder Treatment, Substance Use Disorder Intensive Outpatient, Substance Use Disorder Partial Hospitalization Program,

Yes

No

Unknown

Current Behavioral Health Diagnoses and Medication Information

Primary Diagnosis (DSM-5 or ICD-10 code & name if applicable)

Secondary Diagnosis (if applicable):

Current Medication List (if applicable):

Diagnosis Source, Name, Credentials & Date (If applicable)

Presenting Problems, Current Symptoms & Needs

Why is Therapy being recommended in addition to outpatient mental health treatment/modalities? This section is mandatory from the provider for eligibility. Briefly describe the individuals current problems, symptoms, and needs for community support.

Drugs and/or Alcohol (If used)

Other (please specify)

How did you hear about us?

Certification and Signature

Please review the information above, certify its accuracy, and sign below. Please sign for yourself if you are 18 years and up. OR the Referring provider or parent/guardian please sign form.

Signature

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Date and time

Month

Day

Year

Time

HoursMinutes

All information submitted on this form, including file attachments, meet or exceed confidentiality provisions of the Health General Article of the Maryland Annotated Code, HIPAA regulations and Title 42 C.F.R.

1826 Woodlawn Drive

Suite 3 & 4

Gwynn Oak, MD 21207

Office Phone:

410-800-2121

Emergency 24 hour number:

443-938-9944

Crisis Hotline:

Call 988

Email: Referral@beautifulheartsandminds.org

Interested in Therapy and/or Medication?

Fill out this form.

Online Therapy and Medication Referral Form

Current Behavioral Health Diagnoses and Medication Information

Presenting Problems, Current Symptoms & Needs

Certification and Signature

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