Referral and Placement

MARYLAND CHOICES REFFERAL FORM
Services

Traditional
ATD
AFP

Maryland Choices Care Coodinator Information

	Name:		Work Phone:
	Cell Phone:		Email Address:

Parent/Guardian Information

Parent Name:		Date:
Home Address:		City, State Zip:
Cell Phone:		Email Address:

Child to Receive Treatment---General Information

Name:

Date of Birth:

School:

Grade:

Counselor:

Hair Color:

Eye Color:

Height:

Weight:

Image/Dress:

Distinguishing Marks:

Physical Skill Level:
Very Atheletic Somewhat Athletic Inactive

Reasons for Referral

Precipitating Events:	Suicidal: Yes No Any Attempts?
Substance Abuse:	Self-mutilation: Yes No
Behavioral:	Smokes: Yes No
Violent Behavior:	DJS Involvment: Yes No
Access to Weapons:	DSS Involvment: Yes No

Medical/Psychiatric Profile

Medical History:
Psychiatric History of Counseling
Clinical Assessment (any disorders):

Medications:

Type/How Much:

Moods and Behaviors:
Aggressive Passive
   Respectful Disrespectful
   Compliant    Non-compliant
Verbal    Non-verbal

Physically Acting Out? Yes No

How?:

Requested Services

Crisis Intervention (5140)	Educational Mentor (5521)
Family Assessment (5161)	Life Coach/Independent Living Skills Mentor (5526)
Family Therapy (5110)	Parent & Family Mentor (5522)
Group Therapy (5120)	Recreational/Social Mentor (5525)
Individual Therapy (5100)	Supported Work Environments (5560)
Parenting/Family Skills Training Groups (5528)	Team Meeting (5515)
Substance Abuse Therapy-Group (5121)	Community Supervision (5530)
Substance Abuse Therapy- Individual (5101)	Clinical Mentor (5524)

Plan of Care

Goals and Objectives

Additional Notes

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