Adult Intake Referral

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Clinical Referral

About MPC
Our Services
Our Providers
Patient Forms
Clinical Referral

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Basic Information

Patient Name *

Referral Date *

Street Address *

Apartment

City *

State *

ZIP *

Patient Phone *

Date of Birth *

Month

Day

Year

Last 4 Digits of SSN *0 / 4

Demographics

Gender *MaleFemale

Race/Ethnicity (select all that apply): *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or Latino/a/xMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhitePrefer not to answer

Does the patient speak English? *YesNo

Marital Status *SingleMarriedDivorce

Smoking *YesNo

How many packs a day? *

Is the Patient a Veteran? *YesNoUnknown

Living Situation & Support Contacts

Emergency Contact *

Relationship to Patient *

Emergency Contact Phone *

Legal Guardian

Relationship to Patient

Legal Guardian Phone

Rep Payee

Relationship to Patient

Rep Payee Phone

Probation/Parole Officer

Probation/Parole Officer Phone

Employment & Insurance

Employed *YesNo

Employer *

Are you actively seeking employment? *YesNo

Does the Patient have any type of medical insurance? *YesNo

Insurance Carrier *

ID# *

Group# *

Secondary Insurance Carrier

ID#

Group#

If Patient has no insurance, one of the following Grey Zone eligibility criteria must be checked *HomelessSSDI for mental health reasonsReceived services in the public mental health system within the 2 yearsDischarged from a Maryland psychiatric hospital or residential crisis bed within the past 3 monthsReferred by order of a Conditional ReleaseReleased from Dept. of Corrections/prison/jail within the past 3 monthsN/A

Where is the patient living? *

Client applied forCheck all that applyMedical AssistanceSSI/SSDI

Medical & Mental Health History

Briefly describe the patient’s needs? *

History of psychiatric hospitalizations? *YesNo

Please indicate facilities and dates of service below *

Please attach discharge summary if available

No file chosen

Current Medication(s)List Medication(s)

Medication *

Dosage *

Direction/How Often? *

Has patient ever been diagnosed with Autism, Asperger’s, Pervasive Developmental Disorder (PPD) or any other developmental disability? *YesNo

What was the diagnosis? *

Is patient under a doctor’s care for the above mentioned? *YesNo

Where? *

Mental Health DiagnosisIf Known

Recent Assessment MeasuresOptional

Social/Environmental/Physical Health Issues

Legal & Social History

History of court charges and incarcerations *Check Where ApplicableDrug-relatedTheftAssaultWeapons PossessionSexualN/AOther

Is patient currently registered as a sex offender? *YesNo

Number of arrests in the past 90 days

Current Care Team

Primary Physician *

Physician Phone

Case Manager

Case Manager Phone

Psychiatrist

Psychiatrist Phone

Therapist

Therapist Phone

Referral Source

Is this a self-referral? *YesNo

Please complete the following information and attach a signed release so that we may contact you for follow-up if needed.

If patient is being discharged from the hospital, please send patient’s records upon release.

Contact

Phone

Hospital

If patient is being referred by another organization

Contact

Phone

Organization

Relationship to Patient

Does patient need transportation? *YesNo

Are special accommodations needed? *YesNo

List Accommodations *

Patient Agreement

I wish to be considered for services with MPC Behavioral Health. *YesNo

By signing below, I acknowledge that I have reviewed and agree to the following policies and documents:

Consent to Treat and Patient Rights
Telehealth Services Consent
Electronic Communications Consent
Handbook Acknowledgment
Participant Orientation

My signature below indicates my acknowledgment and agreement to all documents listed above.

Patient Signature - By signing, I acknowledge all documents listed above *

Start signing your signature here

Date *

Save as Draft

Please do not fill in this field.

Where Southern Maryland finds Hope, Help, Health, and Healing.

Trusted behavioral health care serving Southern Maryland with compassion, professionalism, and respect. Veteran-led and minority woman owned.

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Get In Touch

Maryland Location

3050 Crain Highway
Waldorf, MD 20601

info@marylandpsychcare.com
(240) 585-5142
Monday - Friday:
8:00 AM - 6:00 PM
Saturday:
9:00 AM - 2:00 PM

Virginia Location - Coming Soon

13168 Centerpointe Way,
Suite 201
Woodbridge, VA 22193

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If you are experiencing a mental health emergency, please call 911 or go to your nearest emergency room.
For crisis support, call the 988 Suicide & Crisis Lifeline.