Referrals – Empowering Minds Resource Center

Client Information

Referral Date *

Client Name *

Client Contact *

Client Email

Client's Address *

City *

State *

ZIP *

Client's Date of Birth *

Client's SSN *Please enter your Social Security Number without dashes or spaces (e.g., 123456789).0 / 9

Client's Gender *

Client's Highest Grade Level Completed *

Does Client Have a Parent or Legal Guardian? *YesNo

Parent/Guardian Name *

Parent/Guardian Phone *

Parent/Guardian Email Address *

Relationship to Client *

Policy Holder Insurance *

Relationship to Client *

Rates for Selfpay

Initial Consultation (50 Minutes): $155 – $185
Initial Consultation (90 Minutes): $205 – $235
Individual, Couple, or Family Therapy (50 Minutes): $155 – $185
Individual, Couple, or Family Therapy (90 Minutes): $225 – $255

Insurance ID Number *

Insurance Group Number *

Referral Name *

Relationship to Client *i.e., parent, relative, social worker

Referral Contact Phone *

Referral Email Address *

Referring Agency Name *

Referring Agency Address *

City *

State *

ZIP *

Referral Service

Referral Service *

PRP Service Locations *

Harford County School Based Therapy Service Location *

Outpatient Mental Health Center Service Locations *

Is this referral for a minor or an adult? *MinorAdult

Care Coordination Service Locations *

Case Managment Service Locations *

Is this referral for an adult or a minor? *Adult (Ages 18 or older)Minor (Ages 4 -17)

A qualifying diagnosis is REQUIRED to qualify for this program (See Qualifying Diagnosis). If you do not currently have a qualifying diagnosis and wish to have a Comprehensive Diagnostic Evaluation completed, please complete a referral for OMHC Services.

Psychiatric Rehabilitation Program Adult Referral Service

Psychiatric Rehabilitation Program Minor Referral Service

Has client been actively engaged in individual, group, or family therapy? *

THE PARTICIPANT DOES NOT QUALIFY FOR PRP SERVICES. To qualify for PRP Services an individual must be actively engaged in individual, family, or group therapy. If you desire to be enrolled in therapy services, please complete a referral for OMHC Services.

Has client had any psychiatric hospitalizations within the last 3 months? *

Has client been released from inpatient, a day or residential treatment within the past 3 months? *

Has medication been prescribed? *

List Medication(s)

Medication *

Dosage *0 / 10

Frequency *

Route of Administration *

Interval in Hours *Please specify the number of hours between each dose.

Functional Impairments (All referrals for PRP must choose at least three functional impairments.) *Ability to maintain Employment/AcademicsAbility to manage independent activities of daily living (paying bills, maintaining household chores, preparing meals, medication compliance.Ability to maintain a positive support systemAbility to concentrate and follow through on daily tasks and responsibilitiesAbility to manage self care activities (nutrition, hygiene, somatic care appointments)Ability to organize, prioritize and set realistic goals for the futureAbility to maintain needed resources and entitlements to foster independence

Specify example of how this impairment is manifesting in the client's life *

Have the impairments listed above been present for at least? *

Does the patient have marked impairments in the following categories?

Is the child at risk for out of home placement, inpatient hospitalization, or residential care without further treatment from the PRP? *YesNo

Is the child an emerging risk for harm to himself/herself or others? *YesNo

Is the child experiencing significant psychological and social impairments with peers, family and teachers in school? *YesNo

Is the child struggling with age-appropriate development and independent living skills? *YesNo

Please provide brief examples for the areas that were answered with a yes. *

Has client received a mental health diagnosis within the last 2 years? *

Identify DSM-V Diagnosis *

Date of Onset *

Have less intensive levels of treatment (therapy, medication, family/peer support) been determined to be unsafe or unsuccessful for the client? *

Reason for Referral *Please provide sufficient clinical history indicating why prior interventions have been adequate, but unsuccessful. Please provide why prior medications have been adequate, but either unsafe/or unsuccessful.

How did you hear about our services?

Upload Supporting Documents

No file chosen

Upload Supporting Documents ie, Release of Information, Discharge Forms, Diagnostic Eval, Photo ID, Therapy Notes, IEP, etc.

Referring Clinician's Credentials *

Referring Clinician's Signature *

Supervisors Name and Credentials *

If you are making a referral on behalf of another individual, have you informed them that Empowering Minds will be contacting them? *

What is the best means to contact client? *All clients will be contacted within 24 hours

Harford County School Based Therapy Referral Service

Does client have a legal guardian? *

Guardian Name *

Guardian Email Address *

Guardian Phone *

2nd Guardian Name

2nd Guardian Email Address

2nd Guardian Phone

Who has legal and or custodial rights? *

Identify reason for referral *

List any aggressive behaviors (biting, kicking, scratching) *

Has the behavior in school been present for at least? *

Is the behavior isolated to school only? *

Name of School *

Grade *

Guidance Counselor's Name *

Guidance Counselor's Email Address *

Does student have an IEP *

Upload Supporting Documents

No file chosen

Upload Supporting Documents ie, Release of Information, Discharge Forms, Diagnostic Eval, Photo ID, Therapy Notes, IEP, etc.

Outpatient Mental Health Center Referral Service

OMHC Service Type *

Request for Supplemental ServicePsychiatric Rehabilitation ServiceCare Coordination (Minors)Targeted Case Managment (Adults)

Administration Preference of Services *

For onsite services is transportation needed? *YesNo

Do you have a preference for a therapist? *

Which time works for therapy appointments? *

Has client had any psychiatric hospitalizations within the last 3 months? *

Has client been released from inpatient, a day or residential treatment within the past 3 months? *

Has medication been prescribed? *

List Medication(s)

Medication *

Dosage *0 / 10

Frequency *

Route of Administration *

Interval in Hours *Please specify the number of hours between each dose.

List the client’s symptoms and behaviors *

Have the impairments listed above been present for at least? *

Has client received a mental health diagnosis within the last 2 years? *

Identify DSM-V Diagnosis *

Date of Onset *

Upload Supporting Documents

No file chosen

Upload Supporting Documents ie, Release of Information, Discharge Forms, Diagnostic Eval, Photo ID, Therapy Notes, IEP, etc.

How did you hear about our services?

Referring Clinician's Credentials *

Referring Clinician's Signature *

Supervisors Name and Credentials *

If you are making a referral on behalf of another individual, have you informed them that Empowering Minds will be contacting them? *

What is the best means to contact client? *All clients will be contacted within 24 hours

Care Coordination Minor Referral Service

Case Management Adult Referral Service

Has client had any psychiatric hospitalizations within the last 3 months? *

Has client been released from inpatient, a day or residential treatment within the past 3 months? *

Has medication been prescribed? *

List Medication(s)

Medication *

Dosage *0 / 10

Frequency *

Route of Administration *

Interval in Hours *Please specify the number of hours between each dose.

Has client received a mental health diagnosis within the last 2 years? *

Identify DSM-V Diagnosis *

Date of Onset *

Upload Supporting Documents

No file chosen

Upload Supporting Documents ie, Release of Information, Discharge Forms, Diagnostic Eval, Photo ID, Therapy Notes, IEP, etc.

How did you hear about our services?

Referring Clinician's Credentials *

Referring Clinician's Signature *

Supervisors Name and Credentials *

If you are making a referral on behalf of another individual, have you informed them that Empowering Minds will be contacting them? *

What is the best means to contact client? *All clients will be contacted within 24 hours

Therapy Collaboration PRP Services

This form is only to be used for Clients currently enrolled in our PRP Program. The intent is to provide an update for continued services.

Referral Date *

Referral Contact Phone *

Referral Fax

Referral Email Address *

Referral Source Name *

Referral Source Agency *

Referral Address *

Apartment, suite, etc

City *

State *

ZIP *

CLIENT INFORMATION

Client Name *

Date of Birth *

Client's Gender *

Guardian Name *

Relationship *

Client's SSN *Please enter your Social Security Number without dashes or spaces (e.g., 123456789).0 / 9

Medicaid# *

Name of person that client is residing with *

Relationship with client *

Client Address *

Apartment, suite, etc

City *

State *

ZIP *

Home Phone *

Alternative Phone

Other important contact information (e.g. biological family)

Diagnosis *

Please indicate all services being provided and frequency of services

Check All Services *

Select Frequency *

Has medication been prescribed? *

List Medication(s)

Medication *

Dosage *0 / 10

Frequency *

Route of Administration *

Interval in Hours *Please specify the number of hours between each dose.

Indicate which of the following programs) the individual is also receiving services from *

Presenting Concerns/Progress/Comments *

Does client have a history of (check all that apply) *TraumaLegal IssuesSubstance AbuseN/A

Explain *

Has the client been referred to any other less intensive program? *YesNo

When, where, and what was the outcome? *

Referring Clinician's Credentials *

Referring Clinician's Signature *

Supervisors Name and Credentials *

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Locations

Corporate Office

10451 Mill Run Circle
Suite 407
Owings Mills, Maryland 21117
Phone: 410-363-3713
Fax: 410-363-3715

Baltimore City

1800 North Charles Street, Suite 600
Baltimore, Maryland 21201
Phone: 410-625-5088
Fax: 410-625-4980

Baltimore County

3104 Lord Baltimore Drive,
Suite 103
Windsor Mill, Maryland 21244
Phone: 443-893-3928
Fax: 443-200-5032

Prince George’s County

5808 Allentown Way
Temple Hills, Maryland 20748
Phone: 240-719-3968
Fax: 240-838-7040

Harford County

1833A Pulaski Hwy
Edgewood, Maryland 21040
Phone: 443-484-2306
Fax: 443-484-2970

Anne Arundel County

7954 Baltimore Annapolis Blvd
Suite E & F
Glen Burnie, Maryland 21061
Phone: 410-590-3672
Fax: 410-590-3670

Resource Center

105 East 25th Street Baltimore, Maryland 21218
Phone: 410-467-5550
Fax: 410-467-4679

Certification and Accreditation

Referral Line

410-246-0169

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1-800-265-4106 – Complaint Hotline | 443-978-9946 – 24 Hour Hotline

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EMRC Referral Form

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About EMRC

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Locations

Corporate Office

Baltimore City

Baltimore County

Prince George’s County

Harford County

Anne Arundel County

Resource Center

Certification and Accreditation

Referral Line