Referral Form: Somerset County Local Care Team

Instructions
Please complete the form to make a referral to the Local Care Team. Parents/caregivers completing the form should provide as much information as possible. Local Care Team coordinators will assist with completing the form as needed to ensure all relevant information is obtained. Forms must be transmitted using apppropriate encryption to ensure the confidentiality of protected health information. Consents and releases should be obtained as necessary. Access the Local Care Team Directory here.
First Name of Youth*
Middle Name of Youth*
Last Name of Youth*
Youth's Date of Birth*

MonthDayYear
Date
Youth's Gender*
Youth's Race

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderMulti-RacialWhiteOtherPrefer not to answer
Youth's Ethnicity

Latinx, Hispanic, or other Spanish OriginNot Latinx, Hispanic or Spanish OriginPrefer not to answer
What Language is Primarily Spoken at Home?
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What is the Youth's County of Residence*
Is Youth a Maryland Resident

YesNoUnsure
Youth's Current Address*
Facility Name, if Applicable. Leave this line blank for a residence.*
City*
City & zipcode
State*
What is the Youth's Legal Status

Committed to an Agency (List the Agency Below)Co-Committed to Multiple Agencies (List the Agencies Below)Not Committed to an AgencyApproved Voluntary Placement AgreementUnsure
If the Youth is Committed to an Agency/Agencies, List Agency or Agencies
Is the Youth Currently Eligible for Medical Assistance

YesNoUnsure
If the Youth is Currently Receiving Medical Assistance, Enter MA Number Below
Please enter the 11 digit Medical Assistance number.
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Educational Information
Is the Youth Currently Enrolled in School

YesNoUnsure
Current Grade if Enrolled
If Currently Enrolled in School, Which School?
State of School?
Jurisdiction of School Where the Youth is Enrolled
Educational Goal:

DiplomaGEDCertificate of Completion
If there is an IEP/504, when was last date a plan was completed?
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Educational Code - Include Information on the Child/Youth's Primary Disability as Identified on the Youth's Individualized Education Program(IEP) Plan.

01 Autism02 Deaf03 Deaf - Blindness04 Developmental Delay05 Emotional Disability06 Hearing Impairment07 Intellectual Disability08 Orthopedic Impairment09 Other Health Impairment10 Specific Learning Disability (Dyslexia, Dysgraphia, Dyscalculia)11 Speech or Language Impairment13 Traumatic Brain Injury14 Visual Impairment15 Multiple Disabilities (Cognitive, Sensory, Physical)
What is the Youth's Resident School System?
If Not Currently Enrolled in School, What is the Last School Attended?
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Withdrawal or Graduation Date

MonthDayYear
Date
Parent/Guardian Information
Have Parental Rights Been Terminated? If so, whose?
List full name of Legal Guardian #1
Relationship to Child/Youth
Address of Legal Guardian #1
City
State
County of Address of Legal Guardian #1
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Legal Guardian #1 Email
example@example.com
Phone Number of Legal Guardian #1
Please enter a valid phone number.
List full name of Legal Guardian #2
Address of Legal Guardian #2
City
State
Relationship to Child/Youth
County of Address of Legal Guardian #2
Legal Guardian #2 Email
example@example.com
Phone Number of Legal Guardian #2
Please enter a valid phone number.
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Additional Information Regarding the Child/Youth:

	Yes, Currently	No, but Prior	Never	N/A
Multiple Mental Health Diagnoses
Fire Setting
Suicidal Ideation
Suicide Attempt
Substance Use
Pregnant or Parenting
Developmental Disability Diagnosis
Sexually Reactive Behaviors
Denied RTC Placement not Due to Bed Availability
Aggressive Behaviors
Gang Affiliated
Lead Exposure

Parents:

	Mother	Father	Both	N/A
Mental Health History
Substance Use/Abuse History
Incarcerated
Deceased

Provide an Overview of the Youth's Strengths (talents, interests, skills). Please include child's need for activities, need for child or family for future planning,etc
Provide an Overview of the Youth's Clinical Needs. Please include clinical diagnosis, date of diagnoses, prior mental health treatment, any psychiatric hospitalizations in past year &/or emergency room visits/crisis episodes
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Services Received From/Agency Involvement:

	Yes, Currently	No, but Prior	Never	N/A
Department of Social Services
Department of Juvenile Services
Local Behavioral Health Authority
Private Behavioral Health Provider
Developmental Disabilities Administration

Please List Services Received Past and Present. Use the Name of the Agency Listed Above or Private Provider and Dates of Service.

Services Currently Recommended:

	Yes	No	N/A
Counseling/Therapy
Substance Abuse Treatment
Behavioral Supports
Medication Monitoring
Psychiatric Services
Substance Use Education
Fire-Setter Treatment
Medical Care
Trauma-Based Therapy
Psychosocial Evaluation
Neurological Evaluation
Psychological Evaluation
Sex Offender Treatment

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Is the Youth Currently in a Hospital

YesNoOverstaying medical necessity
If yes, What Hospital
Include date of admission & possible discharge date, social worker name and contact information
Is a Residential Placement Clinically Recommended

YesNoUnsure
If Yes, What is the Level of Care Recommended? e.g. group home, RTC, inpatient hospital
If Yes, is this a New Placement or a Transfer between Similar Settings?

NewTransferN/A
Have In-State Resources Been Explored for the Residential Placement?

YesNoN/A
If in-State resources were NOT explored for the residential placement, explain the reasons why below, including the specific services that are not available for in-State programs to be considered.
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Exception Criteria for Out-of-State (OOS) Placement:
(check which applies)

Closer - The OOS placement is closer to the youth’s home than any alternative in-State placement.Proximity - The youth’s permanent placement includes residence with a caregiver in proximity to theCost - The individualized needs of the youth cannot be met through available, appropriate in-StateDetention - The youth is currently in detention, shelter care, or committed to the Department ofIDEA - Compliance with the federal Individuals with Disabilities Education Act (IDEA) requires OOSHospital - The youth is hospitalized in an acute care psychiatric hospital under the following circumstances: 1) committed to DJS, local DSS, or a division of MDH; 2) the treatment team hasdetermined that the youth is ready for discharge; and/or, 3) the only available appropriate placement is OOS.
Is a Voluntary Placement Agreement Being Considered

YesNoN/A
If applicable, List Most Recent Prior Placement
If Prior Placement, List Facility Name
Facility State
If applicable, List Other Preceeding Prior Placement(s)
Is there an Expected Date of Placement?

MonthDayYear
Date
Is there an Expected Date of Discharge, if Youth is Currently Placed?

MonthDayYear
Date
Goals for bringing this case to the LCT & Any Other Relevant Information for the Local Care Team:*
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Name of Person Completing Form*
Are You

Parent/GuardianHospital PersonnelStaff of Local Care Team Member AgencyIf "Other", Please Explain Your Relationship to the Youth
If "Other", Agency &/or Hospital , Please Explain
Provide agency/hospital affiliation
Your Phone Number*
Please enter a valid phone number that can be used to contact you regarding this referral.
Your Email*
example@example.com
For referrals completed by agency/hospital personnel, provide the agency affiliation of the person completing the referral or the name of the hospital where the person completing the referral is employed.
Date Form Completed.*

MonthDayYear
Date
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Should be Empty:

Instructions

Educational Information

Parent/Guardian Information

Exception Criteria for Out-of-State (OOS) Placement: