Internal Referral Form

Referral Information

Referral Date *

Referral Name *

Referral Contact Phone *

Referral Email Address *

Client Information

Client Name *

Date of Birth *

Gender *

SSN# *0 / 11

Has the client received previous mental health services for the services you are referring them to from another agency? *YesNoUnknown

Please ensure that the client does not have an open authorization for the service they are being referred to with another agency/provider

What services is the client currently receiving from Empowering Minds? (check all that apply) *Individual TherapyGroup TherapyMedication ManagementPsychiatric Rehabilitation Program (Minors)Psychiatric Rehabilitation Program (Adults)Care Coordination (Minors)Targeted Case Management (Adults)Targeted Life SkillsBCDSS (Wellness)

Client Current Diagnosis *List specific examples and/or situations that show functional impairment related to the client's diagnosis

Client must have a qualifying diagnosis.

Select Qualifying Diagnosis *

Adminstration Preference of Services *

Presenting Behaviors/Reasons for Referral *Please provide any supporting information or reason for the referral.

Upload Supporting Documents

No file chosen

Signature *

Save as Draft

Referral Information

Client Information

Get Updates And Stay Connected. Subscribe To Our Newsletter.

Harford County