FAMILY TRAUMA SERVICES OF MARYLAND, INC.

Providing comprehensive mental health services to

Children, Adolescents, and Families

LICENSED PROGRAMS;

● Outpatient Services ● Intensive Home-Based Services ●

REFERRAL INFORMATION

DATE OF INQUIRY: _____/______/______ PROGRAM ADMISSION DATE: _____/____ /______

CLIENT NAME: __________________________________________________________________________

ADDRESS: __________________________________________________________ APT #:______________

CITY___________________________________STATE_________ZIP CODE __ __ __ __ __ - __ __ __ __

CLIENT PHONE #______/________-_____________ WORK PHONE # ______/_____-_________

DATEOF BIRTH: ___/_____/ ____ SEX: M___ F___RACE: ______ CLIENT SSN: _ _ _- _ _- _ _ _ _

PLACE OF BIRTH: ______________________________________STATE__________________________

GUARDIAN NAME: _____________________ PHONE #____/_____-_______WORK#_____/_____-_____

PERSON MAKING REFERRAL: ____________________________________________________________

REFERRING AGENCY: ___________________________________________________________________

DAY PHONE#: _____ /______-__________ AFTER HOURS PHONE #_____/______-__________

REQUESTED SERVICES_____________________________________________HOURS______________

OTHER INVOLVED PROFESSIONALS: Y___ N___

NAME _______________________ PHONE #_____/______-_______RELATIONSHIP_______________

NAME _______________________ PHONE #_____/______-_______RELATIONSHIP_______________

NAME ______________________ PHONE #_____/______-_______RELATIONSHIP________________

NAME _______________________ PHONE #_____/______-_______RELATIONSHIP_______________

REASON FOR REFERRALL_______________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

HISTORY OF ABUSE/NEGLECT/LOSS: _____________________________________________________

CURRENTLY INVOLVED IN TREATMENT? Y___ N___ NOT REPORTED___

WITH WHOM? __________________________________________ PHONE # _______/______-________