LCT Referral

IMPORTANT

Please make sure that you have informed the parent/guardian that you are making this referral.
Please provide the parent/guardian with information about the Local Care team and why you would like to make this referral on their behalf.
Please make sure that you have current consent to share information from the parent/guardian for your organization/agency.

Meeting being requested for the following child/youth:*

First NameLast Name

Child/Youth's Date of Birth*

MonthDayYear

What school does the child/youth attend?*

Why are you referring this child/youth?*

Please check whichever applies to this child/youth.*

IEP504Unknown

If child/youth has an IEP, please provide the case manager's name and email.
First Name Last Name Email

If child/youth and family are not receiving services from Maryland Coalition of Families (MCF) or Wraparound Maryland, please STOP and complete the following referrals prior to submitting this form.

**Use the links below to access the referrals. When you click on the link, it will open in a new tab. You will be able to return to complete this referral.

Maryland Coaliton of Families Referral (peer support for parent/caregivers)
Wraparound Maryland Referral (for mental health case management)

If child/youth and family are receiving services from Maryland Coalition of Families (MCF) or Wraparound Maryland and/or referrals have been made, please continue with this section. If not, STOP and see previous section.

Maryland Coalition of Families (MCF):
Family is assigned to an MCF worker.
MCF Caseworker First Name   Last Name   Email
Family is not assigned to an MCF worker.
Referral was submitted on:   Date

Wraparound Maryland:
Youth is assigned a Wraparound worker.
Wraparound Caseworker First Name   Last Name       Email
Family is not assigned to a Wraparound worker.
Referral was submitted on:   Date

Please provide a short summary of why you are making this referral.*

Please provide a brief summary of your agency’s involvement with this child/family including any services provided by your agency.*

Please list your goals for bringing this case to the team.*

Please list family’s known involvement by any other agencies past or present (DJS, DSS, Behavioral Health/Therapist, Community-based agencies, etc.). *

Please provide any current current diagnosis that you are aware of?*

The Local Care Team is a resource for parents/guardians and participation is voluntary. A referral to the Local Care Team will not be discussed by the Local Care Team without a parent/guardian present. Have you informed the parent/guardian that you are making this referral to the Local Care Team? *

Please select from the drop down menu

Parent/Guardian to be contacted:*

First NameLast Name

Parent/Guardian Email*

example@example.com

Parent/Guardian Phone Number*

Please enter a valid phone number.

Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Local Care Team Referral Form