OMHC Referral Form

Outpatient Mental Health Clinic

OMHC Referral Form

Use this form to refer yourself, a family member or a client to our Outpatient Mental Health Clinic (OMHC).

About the OMHC program Looking for the PRP referral form?

Fields marked * are required.

This form is not monitored 24/7. If you or someone else is in immediate danger, call 911. For a mental health crisis, call or text 988 (Suicide & Crisis Lifeline).

1 Referral details

Date of Referral

2 Referral source

The agency or person making this referral. Leave this section blank if you are referring yourself.

Agency / Individual First Name

Agency / Individual Last Name

Phone #

Fax #

Address

City

State

Zipcode

3 Client information

First Name

Last Name

Date of Birth

Gender

Ethnicity

Best Number to Contact

Home Address

City

State

Zipcode

Medical Assistance Number

Is there a current or previous substance use?

If yes, currently in treatment?

Is the client Homeless?

Parent / legal guardian (if the client is a minor)

If legal custody has been determined by the courts, we are required by MD law to obtain a copy of the court order.

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Foster Parent

4 Services requested

Select all that apply.

Mental Health Evaluation/Assessment

Individual Therapy

Psychiatric Rehabilitation Services/ PRP

Psychiatric Services/ Medication Evaluation

5 Reason for referral

Describe the presenting problems. Please be specific.

Reason for referral / presenting problems

Diagnostic interview (if already scheduled)

Scheduled Diagnostic Interview

Date

Therapist

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Heuristic Therapeutic Services is accredited by CARF International.

OMHC Referral Form

OMHC Referral Form

1 Referral details

2 Referral source

3 Client information

Parent / legal guardian (if the client is a minor)

4 Services requested

5 Reason for referral

Diagnostic interview (if already scheduled)

Germantown Office

Silver Spring Office