Minor Intake Referral

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Clinical Referral

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Patient Information

Patient Name *

Date of Birth *

Month

Day

Year

Last 4 Digits of SSN *

Patient Phone *

Street Address *

Apartment

City *

State *

ZIP *

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

Legal Guardian

Legal Guardian Name *

Relationship to Patient *

Guardian Phone *

Marital/Custody Status *Married, living togetherMarried, separatedDivorced - Joint custodyDivorced - Sole custodySingle ParentOther legal arrangement

If custody is shared or there is a custody agreement, please upload court documentation

No file chosen

Additional Representative Payee (if different from guardian)

Rep Payee Name

Relationship to Patient

Rep Payee Phone

Emergency Contact

Emergency Contact Name *

Relationship to Patient *

Emergency Contact Phone *

Legal System Contact

Probation/Parole Officer

Officer Phone

Insurance Information

Does the patient have medical insurance? *YesNo

Insurance Carrier *

Member ID *

Group # *

Eligibility for Services Without Insurance

Select all that apply *HomelessSSDI for mental health reasonsReceived services in the public mental health system within the past 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

Benefit Applications

Client has applied for (check all that apply) *Medical AssistanceSSI/SSDI

Current Situation

Referral Date *

Where is the patient living? *

Briefly describe the patient's needs *

Currently employedYesNo

Employer

Health Behaviors

Smoking *YesNo

Packs per day *

Psychiatric History

History of psychiatric hospitalizations? *YesNo

Facilities and dates of service *

Upload discharge summary (if available) *

No file chosen

Developmental History

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

What was the diagnosis? *

Is patient under a doctor's care for this condition? *YesNo

Provider/Facility name *

Current Diagnoses & Assessments

Mental Health DiagnosisIf known

Recent Assessment MeasuresOptional

Social/Environmental/Physical Health Issues

Legal History

History of court charges and incarcerations (check all that apply) *Drug-relatedTheftAssaultWeapons PossessionSexualN/AOther

Is patient currently registered as a sex offender? *YesNo

Number of arrests in the past 90 days *

Current Medications

Current Medication(s)Click 'Add Medication' to add more medications

Medication Name *

Dosage *

Frequency/How Often *

Prescribed By *

Healthcare Team

Primary Care Physician *

Physician Phone

Psychiatrist

Psychiatrist Phone

Therapist

Therapist Phone

Case Manager

Case Manager Phone

Referral Information

Is this a self-referral? *YesNo

Hospital Discharge Referral

Complete if patient is being discharged from a hospital
Please send patient records upon release.

Hospital Name *

Contact Person *

Contact Phone

Or, if patient is being referred by another organization

Organization Name *

Contact Person *

Contact Phone

Relationship to Patient *

Transportation & Accommodations

Does patient need transportation to appointments? *YesNo

Are special accommodations needed? *YesNo

List accommodations needed *

Guardian Consent for Services

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

Legal Guardian Signature *Legal guardian must sign for patients under 18

Sign here

Date *

Policy Acknowledgments & Consents

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.

Legal Guardian Full Name *Please type your full legal name

Relationship to Patient *e.g., Parent, Legal Guardian, etc.

Legal Guardian Signature *Digital signature acknowledging all policies listed above

Sign here

Date *

Minor Patient Assent (Optional)

Is the patient 12 years of age or older? *YesNo

While guardian consent is legally sufficient, we value the minor patient's understanding and agreement with treatment. If your child is 12 or older, we encourage them to review the policies and provide their assent below.

Has the minor patient reviewed these policies with you? *YesNoPatient prefers not to sign

Minor Patient Signature (Optional Assent) *Patient signature indicates understanding and willingness to participate in treatment

Sign 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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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.