Referral Form
Phone Number
Maryland Medical Assistance, MA, or Medicaid #
Social Security Number
Clinician Phone Number
Clinician Fax Number
Name
Home Address
City, State and Zip
Phone Number
Email Address
Instructions: Please PRINT and fax (cover not required) completed form to 410-625-4980, or email to:
referral@emrcgroup.org
Diagnosis: Individuals must have a MHA approved diagnosis to qualify for PRP services in Maryland.
Code
Code
Code
Diagnosis made by:
Date
F 410-625-4980
www.emrcgroup.org
Empowering Minds Resource Center, Inc.
1800 North Charles, Suite 804
Baltimore, MD 21201
T
410-625-5088
Referral Form 12_19_2016
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.Parent/Guardian Information
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Description
Description
Description
Date of Birth
Client's Age
Sex
Race
First Name, MI, Last Name
Marital Status
Home Address (number, street, and apartment number)
City, S
tate, and ZIP Code
Clinician Name/Organization Name
Clinician Address (number, street, and suite number)
Clinician City, State, and ZIP code
Information About the Individual Being Referred
click to sign
signature
click to edit
Referral Form
www.emrcgroup.org
Empowering Minds Resource Center, Inc.
1800 North Charles, Suite 804
Baltimore, MD 21201
T
410-625-5088
F 410-625-4980
Referral Form 12_19_2016
Presenting Problems, Current Symptoms & Additional Information
Briefly describe individual's current problems, symptoms and needs for community support. Include any information that you
feel will assist in determining eligibility and admission into EMRC's PRP.
Services Needed: Individual needs assistance with: (Check all that apply)
Yes No
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Presenting Behaviors
Does minor have an IEP or 504 Plan?
If so, please provide details
Housing Resources/Support
MHVP/Employment Support
Medical Somatic/Health Promotion
Substance Abuse Issues
Linkage/Accessing Other Services
Legal Issues
Self Care Skills
Social Skills
Independent Living Skills
Cultural Development
Medication Evaluation/Management
Education/Behavioral Support
Referral Source Information
Your name and credentials
Phone Number
Organization
Fax Number
Address (number, street, suite number, city, state, and ZIP code)
Email
I am referring this individual to receive Psychiatric Rehabilitation Services from Empowering Minds Resource Center. I believe that
there is a reasonable expectation that these services will help this individual to improve and/or maintain independence and current
functional level in the community.
Referral Source Signature: Date:
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Substance Abuse Support
click to sign
signature
click to edit
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