• Rev. 01/31/2025

  • REFERRAL FORM: BEHAVORAL HEALTH CARE COORDINATION FOR CHILDREN AND YOUTH/ 1915i

  • Demographic Information

  • Referral Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Parent/Legal Guardian(s) (if legal guardian, a court order must be attached):

  • Ethnicity, Race, Language, and Ability Status

  • Are interpreter services required?
  • Living Situation: Does this youth currently live or have a plan to live in a group home or any other congregate group setting other than a family or foster home?

  • School/Education

  • Special Education Services:

  • Behavioral Health Diagnosed By:

  • Psychosocial/Environmental Elements Impacting Diagnosis:

  • Medical Diagnoses Impacting Behavioral Health Diagnosis:

  • Current Medications (please list names and dosages):

  • Release of Information (please review and have the parent/guardian sign the release):

  • I understand that I am applying for Care Coordination in County. This service has been explained to me and I understand that if approved I will participate in the development of a Plan of Care with a team of people working with my family. I authorize the release of information to the Care Coordination Organization in County 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.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • If you require additional assistance or need further information or clarification about the services, you may contact your local LBHA/CSA.
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  • Rev. 01/31/2025
  • Please indicate the level of care you intend to refer the youth to
  • Children ages 0-5 must receive a score of 3 or higher on the Early Childhood Services Intensity Instrument (ECSII). Children ages 0-5 who have a score of 5 on the ECSII do not also have to meet the requirements listed below in order to be eligible. Children ages 0-5 who have a score of 3 or 4 on the ECSII must meet one of the following criteria:
  • Youth ages 6-21 must receive a score of 3 or higher on the Child and Adolescent Service Intensity Instrument (CASII). Youth ages 6-21 who have a score of 6 on the CASII do not also have to meet the requirements listed below in order to be eligible. Youth ages 6-21 who have a score of 3-5 on the CASII must meet one of the following criteria:
  • Level III referrals require submission of a psychosocial evaluation dated within 30 days of submission of the application. 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).
  • If you require additional assistance or need further information or clarification about the services, you may contact your local LBHA/CSA.
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  • Care Coordination Organization (CCO) Contacts

  • Care Coordination Organization (CCO) Contacts
    Jurisdiction CCO Name CCO Phone # CCO Fax#/ Referral Email
    Allegany Potomac Community Services 301-791-3087 301-393-0730
    Anne Arundel BTST Services 301-477-3339 443-773-5624 / referrals@btstservices.com
    Anne Arundel Empowering Minds Resource Center 410-590-3672 410-590-3670 / referralaa@emrcgroup.org
    Baltimore City Baltimore Crisis Response 443-835-3425 443-835-3025 / cmrefer@bcresponse.org
    Baltimore City Empowering Minds Resource Center 410-625-5088 410-625-4890 / referral@emrcgroup.org
    Baltimore City Hope Health Systems 410-265-8737 410-265-1258 / ccoreferral@hopehealthsystems.com
    Baltimore City Leading By Example 443-438-7614 443-835-4776 / referrals@leadingbyexamplellc.com
    Baltimore City Optimum Maryland 410-233-6200 410-233-6201
    Baltimore City You First Health Systems 301-329-0177 301-825-9777 / info@youfirsthealthsystems.com
    Baltimore County Hope Health Systems 410-265-8737 410-265-1258 / ccoreferral@hopehealthsystems.com
    Baltimore County Wraparound Maryland 443-449-7713 443-451-8268
    Calvert Center for Children 410-535-3047 410-535-3890
    Caroline Wraparound Maryland 410-690-4805 410-690-4806
    Carroll Potomac Community Services 301-791-3087 301-393-0730
    Cecil Advantage Psychiatric Services 410-686-3629 Ext. 409 410-780-7178
    Charles InnerSourced Solutions 240-207-4513 240-846-6037 / ccoreferrals@innersourcedsolutions.com
    Dorchester Wraparound Maryland 410-690-4805 410-690-4806
    Frederick Potomac Community Services 301-791-3087 301-393-0730
    Garrett Burlington United Methodist Family Services 301-334-1285 301-334-0668
    Harford Empowering Minds Resource Center 443-484-2306 443-484-2970 / referralhc@emrcgroup.org
    Howard Center for Children 301-609-9887 301-609-7284 / CCOreferralsHOWARD@center-for-children.org
    Kent Wraparound Maryland 410-690-4805 410-690-4806
    Montgomery Advanced Behavioral Health 301-345-1022 301-560-5558 / vkurdian@abhmaryland.com
    Montgomery Volunteers of America 240-696-1565 301-306-5105
    Prince George's BTST Services 301-477-3339 443-773-5624 / referrals@btstservices.com
    Queen Anne's Wraparound Maryland 410-690-4805 410-690-4806
    St. Mary's Center for Children 301-475-8860 301-475-3843
    Somerset Wraparound Maryland 410-219-5070 410-219-5072
    Talbot Wraparound Maryland 410-690-4805 410-690-4806
    Washington Potomac Community Services 301-791-3087 301-393-0730
    Wicomico Wraparound Maryland 410-219-5070 410-219-5072
    Worcester Wraparound Maryland 410-219-5070 410-219-5072
  • Should you require additional assistance or need information or clarification about services in your jurisdiction, please contact your Local Behavioral Health Authority/Core Service Agency (LBHA/CSA). A full directory of LBHAs/CSAs is available at https://mabha.org/getting-help/.
  • last updated 01/13/2025
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