Place a referral

OMHC Referral Form

These forms are used to make a referral to AGS Outpatient Mental Health Clinic (OMHC) Program. Fax completed form to 410-276-4070.

Download OMHC Referral Form as (PDF) or (Word)

You can also use the below form to make a referral. To submit a PRP referral click here.










*SOCIAL SECURITY NUMBER MUST BE KNOWN TO PROCESS REFERRAL*

Referral Source Information:






Parent/Guardian Information:





*A LEGAL DOCUMENT MUST BE PRESENTED TO SHOW GUARDIANSHIP*

Please answer the following information:










REASON FOR REFERRAL: In your own words, describe the child/adult in need for therapy services. Please describe any behaviors the child/adult is exhibiting. Please specifically note any of the following whether current or a history of: Recent Hospitalizations, Suicide Attempts or Ideation, Self‐harm, Violence towards others, Aggression, Domestic Violence, Psychotic Symptoms, Substance Abuse, Behavior Problems, & Mood Related Symptoms.

Electronic Signature



I agree and understand that checking this box constitutes an electronic signature.



 

 

 

agsllcPlace a referral