Community Behavioral Health Professional Referral Form

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Please answer every question in this form so our intake team can expedite your referral to allow for the patient's appointment to be made as soon as possible.

IDENTIFYING INFORMATION

Full Legal Name (As It Appears on Patient's ID) *

Patient's Date of Birth *

YYYY

Patient's Social Security Number, if available

###-##-####

Best Contact Number for Patient *

(###)-###-####

Address (Street Number, Street Name, City, State, and Zip Code)

Patient's Email Address

Race

White

Black or African American

American Indian or Alaskan Native

Asian

Native Hawaiian and Other Pacific Islander

Hispanic or Latinx

Two or More Races

Other:

Clear selection

Gender

Male

Female

Transgender Male

Transgender Female

Other

Prefer Not to Say

Clear selection

REFERRING PHYSICIAN OR OTHER PROVIDER CONTACT INFORMATION

Physician/Other Provider/Agency Name *

Physician/Other Provider/Agency Phone Number *

(###)-###-####

Physician/Other Provider/Agency Email Address

(###)-###-####

Physician/Other Provider/Agency Fax

INSURANCE INFORMATION

Please enter if available. If you do not have this information, please skip this section. We will contact the patient to obtain the information and verify insurance prior to scheduling their first appointment.

Insurance Carrier Name

Insurance Carrier Plan

Insurance Member ID Number

Group Number

Claims Phone Number

Claims Address (including city, state, and zip)

Policy Holder Name

Policy Holder Date of Birth

YYYY

Policy Holder Social Security Number

Secondary Insurance Carrier Name:

If none state N/A

Secondary Insurance Carrier Plan:

Secondary Insurance Member ID Number:

Secondary Group Number:

Secondary Insurance Claims Phone Number:

Secondary Insurance Claims Address:

Will the patient require a sliding scale payment option?

Yes

Clear selection

REASON FOR REFERRAL

Please explain the reason for the referral *

Clinic Location (select more than one if you are interested in referring for services available at different locations) *

Cambridge

Centreville

Chestertown (Substance Abuse and School Based only)

Columbia

Easton

Princess Anne (Substance Abuse only)

Salisbury

Snow Hill

Required

Specialty Programs (Please indicate if you are interested in referring one or more of the following specialty services) *

Salisbury Intensive Outpatient Program (IOP) for Children

Salisbury Intensive Outpatient Program (IOP) for Adults

Salisbury Transcranial Magnetic Stimulation (TMS)

Substance Abuse and Mental Health treatment (including Medication Assisted Treatment)

Substance Abuse and Mental Health Intensive Outpatient or Partial Hospital Program

Easton Transcranial Magnetic Stimulation (TMS)

Bariatric Surgery Clearance (You will have to complete a CBT program to receive clearance)

Esketamine (Spravato) Nasal Spray

Psychiatric Rehabilitation Program (PRP) only (please note this is only available to patients with Medicaid/Medical Assistance who meet criteria for severe mental illness)

Court Ordered Forensics (non-Substance) Treatment (Salisbury and Princess Anne only)

Anger Management for Adults (Salisbury and Princess Anne only)

Child Respite Program

School Based Therapy (please indicate which school system in the Reason for Referral)

Other:

Required

Note About TMS and Spravato

Please be aware patients who have failed at least 2 antidepressant trials and meet criteria for treatment resistant major depressive disorder are eligible for these services.

Patients may not be prescribed or actively take benzodiazepines, stimulants, MAOIs, or take any recreational drugs in order to receive these services. If their urine drug screen is found positive for any of these substances, treatment will be immediately terminated for the patient's safety.

Patients must not have any metal implants in order to receive TMS.

Patient's primary medical diagnoses *

Please list any of the patient's seasonal, food, or medication allergies *

Current Medications *

Thank you for completing this form. For TMS, Esketamine (Spravato), Substance Abuse, and Psychiatric Rehabilitation Program (PRP) Services, please complete the follow up questions in the following sections. If you are not referring to any of those services, please skip to the end of the questionnaire to submit your referral.

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