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  • Maryland Wellness Referral Form

  • Date*
     - -

  • Client Information

  • Birthdate*
     - -
  • Do you currently experience homelessness or lack stable housing?
  • Format: (000) 000-0000.
  • Preferred Contact Method (Select all that apply.)

  • By selecting a contact method, you conset to being contacted by Maryland Wellness via the method(s) chosen.

  • Demographics

  • Gender Identity (Select all that apply.)*
  • Pronouns (Select all that apply.)*
  • Race/Ethnicity (Select all that apply.)*

  • Insurance Information

  • Insurance Provider*
  • Do you currently have access to your insurance card?*
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  • Do you currently have access to your ID card?*
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    • Parent/Guardian Information (if applicable) 

    • Parent/Guardian Information

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Referral Information  

    • Referral Details

    • How did you hear about Maryland Wellness?*
    • Are you completing this form for yourself or someone else?*
    • Which service are you referring to? (Select all that apply.)*
    • Are you referring an adult or minor for Targeted Case Management?
    • Are you a licensed clinician able to provide a qualifying diagnosis?
    • Is the individual an adult or a minor?

  • Psychiatric Rehabilitation Program (PRP) Eligibility Information

    • For Adult Clients (18 Years and Older) 
    • Select all qualifying diagnoses that apply.*
    • If psychosis is noted as the diagnosis (DX), please indicate the type:
    • Select the services or supports that have been tried*
    • Select the areas of impairment experienced by this individual due to their illness (Must select at least 3)
    • Select the areas of impairment experienced by this individual due to their illness (Must select at least 3)*
    • Select the skills needed to aid in the individuals recovery (Must select at least 3)*
    • Have peer supports or other informal supports, such as family, been utilized?
    • Has targeted case management been attempted?
    • Has group therapy been utilized?
    • Is the individual currently employed?*
    • Is the individual currently seeking a job?*
    • Has the individual been referred for or are they currently receiving Supported Employment Services?*
    • Is the individual currently taking any medication?*
    • Are any of the medications prescribed for Major Depressive or Bipolar Disorder?*

    • If the individual is taking multiple medications, please list each medication along with its name, dosage, and frequency. Use the 'Add Another Medication' button to include additional medications.

    • Providers must complete at least 3 our of the following 7 sections:

  • Psychiatric Rehabilitation Program (PRP) Eligibility Information For Adolescents

    • For Minor Clients (Under 18 Years Old) 
    • Select the services or supports that have been tried (select all that apply)*
    • Has medication been considered?*
    • Select the areas of impairment experienced by this individual due to their illness (Must select at least 3)
    • Select the areas of impairment experienced by this individual due to their illness within the past three months*
    • Select the areas of risk the individual is experiencing*
    • Select the skills needed to aid in the individuals recovery (Must select at least 3)*
    • Is the minor currently employed?*
    • Is the individual currently seeking a job?
    • Has the individual been referred for or are they currently receiving Supported Employment Services?*

    • Providers must answer 2 of the first 3 Functional Criteria questions. Questions 4 and 5 are mandatory.

    • 3. Does the minor have significant psychological or social impairments causing serious problems with peer relationships and/or family members?
    • 5. Has the youth made progress toward age-appropriate development, individual functioning, and independent living skills?*

  • 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?
  • Check all that apply:

  • 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?

  • Please specify the level of care to which you are referring the youth

    You must select the required items for one level of care. Only one level may be chosen.
  • Level I - General (must select at least two items):
  • Level II - Moderate (must select at least 3 items) :
  • Level III - Intensive (must meet the below criteria based on age) :

  • Level III referrals require submission of a psychosocial evaluation dated within 30 days of submission of the referral. This document can be uploaded with this referral. This evaluation must have an assignment of a Diagnostic and Statistical Manual (DSM) diagnosis or Diagnostic Criteria 0-5 (DC 0-5) and address the following:

    I. Identifying information.

    II. Reason for referral.

    III. Reports reviewed to complete this referral.

    IV. Risk of Harm - Indicate child’s or youth’s potential to be harmed by others or cause significant harm to self or others.

    V. Functional Status - Indicate the degree to which the child or youth is able to fulfill responsibilities and interact with others. Include educational.

    VI. Co-Occurrence of Conditions - Developmental, medical, substance use, and psychiatric. Include DSM 5 diagnosis and medications, both current and past.

    VII. Recovery Environment - Indicate environmental factors that have the potential to impact the child’s or youth’s efforts to achieve or maintain recovery. Include description of family constellation and commitment.

    VIII. Resiliency and/or Response to Services - Indicate the child’s or adolescent’s ability to self-correct when there are disruptions in the environment. Include any major life changes and how the child or adolescent responded.

    IX. Involvement in Services - Indicate the quantity and quality of the child’s/youth’s and primary care taker’s involvement in services. Include involvement with other agencies; list all inpatient and outpatient treatments, and out-of-home placements (i.e., group homes, shelters, foster care, or RTCs).

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  • Referring Provider Information

    Use this section if you are completing the referral on behalf of someone else.
  • If applicable, do you intend to remain the treating therapist?*
  • Format: (000) 000-0000.
  • Date*
     - -

  • Optional Notes and Additional Documents

    Use this section to provide any additional information or upload relevant documents that may support this referral.
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