Mental Health Case Management
Youth Care Coordination (up to 18 years old)
Complete this section for the person being referred
Referral Date
*
-
Month
-
Day
Year
Date
What county does the person being referred reside in currently?
*
Please Select
Caroline County
Dorchester County
Kent County
Queen Anne County
Somerset County
Talbot County
Wicomico County
Worcester County
Name of Person Being Referred
*
First Name
Last Name
Guardian's Name
*
First Name
Last Name
Phone Number of Person Being Referred
*
Please enter a valid phone number.
Age of the person being referred
Date of birth of the person being referred
-
Month
-
Day
Year
Date
Gender and Preferred Pronoun
Race
Address (if known)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Is the person being referred privately insured?
*
Yes
No
Unknown
Medicaid Number or Social Security Number
Reason for this referral
Mental Health Diagnosis
Is this participant currently enrolled in PRP?
*
Yes
No
Unknown
Is the youth currently enrolled in outpatient mental health treatment?
Referral Source (your information)
Your name
*
First Name
Last Name
Your Phone Number
*
Please enter a valid phone number.
Your Email
example@example.com
Signature-By signing I confirm that I understand that I am applying for Care Coordination. This service has been explained to me and I understand that if approved I will participate in development of a Plan of Care with a team of people working with my family. I authorize the release of information to Wraparound Maryland, Inc. so they can conduct a full screening and initiate an eligibility determination by the Administrative Service Organization (ASO) to determine my eligibility for Care Coordination services. I understand that I may revoke my permission at any time by written or verbal request.
Submit
Submit
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