State of Maryland Montgomery County Local Care Team Referral Form

State of Maryland Montgomery County Local Care Team Referral Form

Effective June 1, 2022
Instructions
- Please complete the form to make a referral to the Local Care Team.
- Parents/caregivers who are completing the form should provide as much information as possible. The Local Care Team coordinators will assist with completing the form as needed to ensure all relevant information is obtained.
- Forms must be transmitted using appropriate encryption to ensure the confidentiality of protected health information.
- Consents and releases should be obtained as necessary. In addition to completing this referral form, please also submit a Consent to Release form.
- Access the Local Care Team Directory here

Name of Person Completing Form
Person Completing this Form*

First NameLast Name
Are You:*

Parent/GuardianHospital PersonnelStaff of Local Care Team Member AgencyOther
If "Other", Please Explain Your Relationship to the Youth
Your Phone Number*
Please enter a valid phone number that can be used to contact you regarding this referral.
Your Email*
example@example.com
Agency/Hospital
For referrals completed by agency/hospital personnel, provide the agency affiliation of the person completing the referral or the name of the hospital where the person completing the referral is employed.
Date Form Completed. *

MonthDayYear
Use the calendar to select a date. The default is today, but the date can be changed.

Efforts to Secure a Placement
What is the Expected Date of Placement?

MonthDayYear
Date
What is Expected Date of Discharge if Youth is Currently Placed?

MonthDayYear
Date
List all Applications to in-State and OOS Facilities:
Other Information:

	Yes, Currently	No, but Prior	Never	N/A
Aggressive Behaviors
Pregnant or Parenting
Fire Setting
One or Both Parents Deceased
Gang Affiliated
One or Both Parents Incarcerated
One or Both Parent's Substance Use/Abuse History
Lead Exposure
Substance Use
Substance Exposed Newborn
One or Both Parent's Mental Health History
Multiple Mental Health Diagnoses
Suicidal Ideation
Suicide Attempt
Developmental Disability Diagnosis
Sexually Reactive Behaviors
Denied RTC Placement not Due to Bed Availability

	Yes, Currently	No, but Prior	Never	Applied
Department of Social Services
Department of Juvenile Services
Developmental Disabilities Administration
Local Behavioral Health Authority
Private Behavioral Health Provider

Name of Person Completing Form