System of Care and Healthy Transitions Referral Form

Grant

System of Care (SOC) - Children and youth (birth-21) who have or are at risk for serious emotional disturbances (SED) and entering the child welfare or juvenile justice systems, and their families.

Healthy Transitions (HT) - Youth and young adults (16-25) who have, or are at risk of developing, severe mental health conditions and who can benefit from transition support services and care coordination.

Required

Client Information

First Name: *

Required

Last Name: *

Required

DOB: *

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Home Street Address: *

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City: *

Required

State: *

Required

Zip Code: *

Required Please enter valid 5 digits number

Phone number: *

Required Please enter valid 10 digit number

Email:

Invalid Email

Ethnicity: *

Select Not Hispanic/Latinx Hispanic/Latinx Chose Not to Respond Required

Did Client consent to this referral? *

Select Yes No Client Unaware Required

Race: *

Select African American, Black or African American Indian or Alaska Native Asian Biracial or Multiracial Native Hawaiian or Pacific Islander White Chose Not to Respond Required

Gender: *

Select Boy/Man Girl/Woman Non-Binary, Genderfluid, or Genderqueer Questioning Does Not Know Chose Not to Respond Required

Preferred Pronouns: *

Select He/Him/His She/Her/Hers They/Them/Theirs Chose Not to Respond Required

Current Agency Involvement (if applicable, select multiple):

Select Department of Social Services Department of Juvenile Services Department of Family Services (Children Youth and Family services, Children in need of services, Local care team) Developmental Disabilities Administration Local Behavioral Health Authority Private Behavioral Health Provider Probation and Parole Courts (Mental health court, Drug court, Truancy court)

Current School Name (if applicable):

Current Grade/Highest Grade Completed (if applicable):

Select Pre-K Kindergarten 1 2 3 4 5 6 7 8 9 10 11 12 Post-secondary

Caregiver Information

Caregiver Full Name:

Address:

Phone number:

Please enter valid 10 digit number

Email:

Invalid Email

Relationship To Client:

Did Caregiver Consent To Referral?:

Select Yes No

Is the Caregiver in need of services?

Select Yes No Unsure

Ethnicity:

Select Not Hispanic/Latinx Hispanic/Latinx Chose Not to Respond

Race:

Select African American, Black or African American Indian or Alaska Native Asian Biracial or Multiracial Native Hawaiian or Pacific Islander White Chose Not to Respond

Gender:

Select Boy/Man Girl/Woman Non-Binary, Genderfluid, or Genderqueer Questioning Does Not Know Chose Not to Respond

Preferred Pronouns:

Select He/Him/His She/Her/Hers They/Them/Theirs Chose Not to Respond

Emergency Contact 1

Name :

Phone Number:

Please enter valid 10 digit number

Emergency Contact 2

Name :

Phone Number:

Please enter valid 10 digit number

Insurance Information

Does the Client have insurance? *

Select Yes No Unsure Required

Insurance Co. Name:

Member Number:

Group Number:

Referral Information

Referral Date: *

Required

Referral Source:*

Select Self Family member or friend Health care provider School Community Organization/ Provider Tabling Event or Other Outreach Local Care Team Children in need of supervision (CINS) Department of Social Services Department of Juvenile Services Court Local Behavioral Health Authority Adams House (Bridge Center) Promise Place/ Shelter Law Enforcement Hospital Urgent Care Crisis services, Mobile Response Team Inpatient Treatment Facility Outpatient Mental Health Clinic (OMHC) Health Department Required

Referral Reason: *

Select Clinical Services Clinical and Supportive/Transition Services Transition Services Family Support Services Youth / Peer Engagement Services Required

Additional Explanation for Referral:

Interpretation Services Required: *

Select Yes No Required

Language Preference: *

Select English Spanish American Sign Language Other Required

Client/Family choice of provider:

Select iMind Behavioral Health Maryland Coalition of Families (MCF) Maryland Family Resource (MFR) National Alliance on Mental Illness (NAMI) Synergy Family Services Pathways (Supported Employment Program)

Does Client have a confirmed mental health diagnosis? *

Select Yes No Unsure Required

Mental Health Diagnosis

Referrer Information

Name of Referring Organization: *

Required

Referrer Full Name: *

Required

Referrer Phone number: *

Required Please enter valid 10 digit number

Referrer Email: *

Required Invalid Email

File Upload:

Upload any documents to support this referral

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