Referral Form
Instructions
Please email to referrals@livebenevolent.org
First Name, MI, Last Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
Client's Age
Marital Status
Sex
Race
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Insurance Type
Clinician Name/Organization Name
Clinician Address (number, street, and suite number)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinician Phone Number
Please enter a valid phone number.
Clinician Fax Number
Please enter a valid phone number.
Parent/Guardian Information
First/Last Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Diagnosis
Individuals must have a MHA approved diagnosis to qualify for PRP services in Maryland.
Code
Description
Code
Description
Code
Description
Diagnosis made by:
Date
-
Month
-
Day
Year
Date
Presenting Problems, Current Symptoms & Additional Information
Briefly describe individual's current problems, symptoms and needs for behavioral health support.
Services Needed
Individual needs assistance with
(Check all that apply)
Self Care Skills
Social Skills
Independent Living Skills
Cultural Development
Medication Evaluation/Management
Education/Behavioral Support
Housing Resources/Support
MHVP/Employment Support
Medical Somatic/Health Promotion
Substance Abuse Issues
Linkage/Accessing Other Services
Legal Issues
Substance Abuse Support
Presenting Behaviors
Does minor have an IEP or 504 Plan?
Yes
No
If so, please provide details
Referral Source Information
Name and credentials
Name
Credentials
Organization
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consent
I am referring this individual to receive services from Live Benevolent. I believe that there is a reasonable expectation that these services will help this individual to improve and/or maintain independence and current functional level in the community.
Signature
Date
-
Month
-
Day
Year
Date
Submit Referral
Should be Empty: