Welcome to the SOC and Healthy Transitions Referral
SOC 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 for developing sever mental health conditions, entering or aging out of foster care, or entering or transitioning out of juvenile justice care or custody.
Required
Client Information
First Name:
*
Required
Last Name:
*
Required
DOB:
*
Required
Home Street Address:
*
Required
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
Emergency Contact 1
Name :
Phone Number:
Please enter valid 10 digit number
Emergency Contact 2
Name :
Phone Number:
Please enter valid 10 digit number
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
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
Insurance Information
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
Required
Referral Reason:
*
Select
Clinical Services
Non-clinical 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
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
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
File Upload:
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