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Refer your client to us!

If you are active Medical professional, Therapist, and/or Psychiatrist please fill out this form.

Online Adult PRP Referral Form

All questions with * are required

Does the Client have a legal guardian?
Yes
No
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)
Presenting Problems, Current Symptoms & Needs
Stressors Impacting Functioning
Referring Provider Information
Referral Source type
Licensure Status for Referral Review

Certification and Signature

Please review the information above, certify its accuracy, and sign below.

Please acknowledge
I certify that I am the referring provider or authorized representative and that the information provided is accurate to the best of my knowledge. I understand that my electronic signature will be recorded along with a system-generated date and time.
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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

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Office Phone:

410-800-2121

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Emergency 24 hour number:

443-938-9944

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Crisis Hotline:

Call 988

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Email: Referral@beautifulheartsandminds.org

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