Talbot County Local Care Team Referral revised Oct. 2023

Talbot County Local Care Team (LCT) Referral
Thank you for referring to the Talbot Local Care Team. If you have any questions or need assistance please contact Jan Willis at talbotlct@talbotfamilynetwork.org or 443-366-2511 (phone/text).
Section 1. Personal Information
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Gender*
Race*
Primary Parent/Guardian's Name*

First NameLast Name
Address Primary Parent/Guardian*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Parent/Guardian Phone Number*
Please enter a valid phone number.
Primary Parent/Guardian's Email*
example@example.com
Primary Parent's Preferred Method of Communication

PhoneTextEmail
Secondary Parent/Guardian Name

First NameLast Name
Secondary Parent/Guardian Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Parent/Guardian Phone Number
Please enter a valid phone number.
Secondary Parent/Guardian Email
example@example.com
Child's Insurance Status
List name, age and relationship to the child of everyone that resides in home
List Family Strengths*
What are the issues you would like to see the LCT address?*
Section 2. Referring Agency/Individual Information
Referring Agency/Organization*
Agency Contact*

First NameLast Name
Email of Agency Contact*
example@example.com
Phone Number of Agency Contact
Please enter a valid phone number.
Please list all other Agencies/Organization known to be involved with the child

Department of Social ServicesHealth DepartmentDepartment of Juvenile ServicesTalbot County Public SchoolsDevelopmental Disabilities AdminDORs - Division of Rehabilitation ServicesMid-Shore Behavioral HealthCASA - Court Appointed Special AdvocateMaryland Coalition of FamiliesWraparound MDMobile CrisisOther
Please list Mental Health Provider, if applicable, including contact information
Give a brief summary of the Agency's involvement including services that have or are being currently provided.*
Please state reason for referral at this time*
Section 3. Health - Medical/ Mental Health Information
Please list child's current medical and mental health diagnoses, if known
Please list child's current medications, if known
Please list any prior hospitalization, medical or mental health, if known
Section 4. Educational Information
Is the Child currently enrolled in School? If yes, please list school below.

YesNoPendingOther
Current School Placement
Current Grade Level, if enrolled in school
Does the Student have a current IFSP, IEP or 504 Plan?

Individual Education Plan504 PlanReferral MadeIndividualized Family Service PlanNoUnknown
Section 5. Persons to be invited to the LCT meeting
Please list individuals working with the child and family that it would be helpful to have at the LCT meeting. Also include key family members that are supportive. Please include emails.*
REQUIRED NEXT STEP
- Email the electronic Talbot LCT Consent form to the parent/guardian via this link
- Or if you are a parent/guardian who is self referring, complete the electronic Talbot LCT Consent form.
The referral is NOT complete without a consent form.

If a paper consent is preferred, please use the hardcopy version and scan and email the consent form to talbotlct@talbotfamilynetwork.org.
Should be Empty:

Talbot County Local Care Team (LCT) Referral

Thank you for referring to the Talbot Local Care Team. If you have any questions or need assistance please contact Jan Willis at talbotlct@talbotfamilynetwork.org or 443-366-2511 (phone/text).

Section 1. Personal Information

Section 2. Referring Agency/Individual Information

Section 3. Health - Medical/ Mental Health Information

Section 4. Educational Information

Section 5. Persons to be invited to the LCT meeting