Behavioral Health Referral

REFERRAL SOURCE

Date of Referral*

Referring Organization / School*

Referrer Name*

Title / Role & Relation to Client

Phone*

Email*

Best Way for CTM to Follow Up

SERVICE(S) REQUESTED

Check all that apply

Services Requested

Outpatient Therapy (Individual / Family)
Medication Management / Psychiatric Evaluation
Psychiatric Rehabilitation Program (PRP)
Health Homes / Care Management / Care Coordination
Unsure / Consultation Requested
Other

Other:

REASON FOR REFERRAL

Briefly describe the client's needs / primary concern(s)*

Is client currently on medication?

Unknown
No
Yes - list:

Yes - list:

CLIENT INFORMATION

Name, DOB, SSN and Medicare/Medicaid # are required to locate the client in NS or Carelon

Client Name*

First Last

Date of Birth*

Gender*

Male
Female

Medicare # (if applicable)

Medicaid # (11 digits, if applicable)

Home Address (include Apt #)

Home Address City State Zip

Home Phone

Cell Phone

Client Email

Client Language

English
Spanish
Other:

Other:

School / Grade (if student)

PARENT / GUARDIAN / OTHER CONTACT

Required for minors; case worker or other contact for adults.

Name

Relationship to Client

Phone

Email

Preferred Contact Time

Preferred Contact Method

INSURANCE

If known. CTM will verify coverage directly.

Insurance

Maryland Medicaid - MCO:
Medicare
Private Insurance:
Uninsured
Unsure

Maryland Medicaid - MCO:

Examples of MCOs: Wellpoint (Amerigroup), UnitedHealthcare, Priority Partners, CareFirst CHPMD, MedStar

Private Insurance:

Client Name:

REQUIRED REPORTING DATA

This information is required to obtain authorization from NS or Carelon.

Race

White
Black / African American
Asian
American Indian
Native Hawaiian or Other Pacific Islander
Not Available

Check all that apply

Ethnicity

Not Hispanic/Latino
Hispanic/Latino
Not Available

Marital Status

Living Situation

Other:

Employment Status

COMMUNICATION / CONSENT

Has the client (or parent/guardian, if a minor) been informed of this referral to CTM?

Yes
No

Does the client (or parent/guardian) agree to be contacted by CTM?

Yes
No
Unsure

Authorization for the exchange of protected health information will be obtained separately when required. Submitting this referral does not replace CTM's intake, consent, eligibility or clinical assessment process.

CTM USE ONLY

Date Received

Assigned To

First Contact Date

Located In:

NS
Carelon

Authorization #: