Maryland Wellness Referral Form

Adult Targeted Case Management Eligibility

Only available in Allegany County
Does the individual currently have a mental health diagnosis that is negatively impacting their life?

YesNo
Please list the diagnosis(es), including ICD-10 codes, if known.
Check all that apply:

The individual is at-risk of or needs continued community treatment to prevent inpatient psychiatric treatmentThe individual is at-risk of or needs community treatment to prevent being homelessThe individual is at-risk of incarceration or will be released from a detention center or prisonThe individual committed as not criminally responsible who is conditionally released from a BHA facilityThe individual is in a BHA facility or a BHA-funded inpatient psychiatric hospital that requires community services

Minor Targeted Case Management Eligibility

Only available in Garrett and Allegany Counties.
Does the individual currently have a mental health diagnosis that is negatively impacting their life?

YesNo
Please list the diagnosis(es), including IOCD-10 codes, if known.
Check all that apply:

The individual is at-risk of, or needs continued community treatment to prevent inpatient psychiatric treatmentThe individual is at-risk of, or needs continued community treatment to prevent treatment in a residential treatment center (RTC)The individual is at-risk of and out of home placement due to multiple behavioral health stressorsThe individual requires community treatment and support in order to prevent or address emergency room utilization due to multiple behavioral health stressorsThe individual requires community treatment and support in order to prevent or address homelessness or housing instability, or otherwise lacking in permanent, safe housingThe individual requires community treatment and support in order to prevent or address arrest or incarceration due to multiple behavioral health stressors

Referring Provider Information

Use this section if you are completing the referral on behalf of someone else.
Referring Provider Name

First NameLast Name
Title and Credentials*
NPI Number *
If applicable, do you intend to remain the treating therapist?*

YesNoN/A
If applicable, provide your supervisor's name and credentials (for LMSW or LGPC).
Agency/Organization*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Signature*

Powered by Jotform SignClear
Please include your full name, credentials (e.g., LCSW-C, MD, RN), and the date in the signature box for the referral to be processed successfully.
Date*

MonthDayYear
Date

Optional Notes and Additional Documents

Use this section to provide any additional information or upload relevant documents that may support this referral.
Additional Notes
You may download the Maryland Wellness Release of Information, have the individual sign it, and upload it with your referral to support coordination of care.
Additional Healthcare Documentation

If you are a partner completing a referral, please upload a completed Release of Information (ROI) if available. Providing this document allows us to share status updates as individuals move through our intake process.
Cancelof
Please verify that you are human*
Should be Empty:

Client Information