LCT Referral

Local Care Team Referral Form

**This form is to be filled out by an organization/agency referring a child/youth to the LCT.**
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
Youth's Gender
Youth's Race
Youth's Ethnicity
Is the youth currently eligible for Medical Assistance (Medicaid)?
What school does the child/youth attend?*
Why are you referring this child/youth?*

Child/Youth is being discharged from residential treatment.Child/Youth is being discharged from acute residential treatment with a recommendation for higher level of care.Child/Youth has a recommendation for a higher level of care.Child/Youth is currently in a hospital setting and at-risk of overstay.Child/Youth has been identified as CINS-Child in Needs of Services.Child/Youth has been recently adopted and parent/guardian is in need of resources/supports.Parent/Guardian has requested a Local Care Team referral.Parent/Guardian has requested a Voluntary Placement Agreement.Medical Professional/Therapist has been unable to identify community resources to meet identified need.Education Professional has been unable to identify community resources to meet identified need.Multi-agency service coordination is needed to meet child/youth needs.Child/Youth is not connected to any community resources.Family is in need of resources to meet basic needs (housing, food, etc.)
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