Referrals

Make a Referral

For schools, medical providers, agencies, community organizations, families, and individuals across Maryland.

Referral form

Fields marked Required must be filled in. Please don't include Social Security numbers or detailed medical history.

About you

I am referring Required

Myself My child or a person in my care Someone, in a professional capacity

Person being referred

Full name Required

Age group Required

Maryland county or Baltimore City Required

Client's home address

Street address Required

Apartment, unit, or suite

City or town Required

State Required

ZIP code Required

Client or guardian phone Required

Client or guardian email Required

Preferred contact method Required

Phone Email

Service requested

Service Required

Insurance Required

Choosing a plan doesn't confirm we're in network. We'll check coverage before the first visit.

Brief reason for referral

A sentence or two is enough. Please leave out diagnoses, medications, and other medical history; our intake team will collect what's needed.

0 of 300 characters

Sending a referral doesn't guarantee an appointment. For emergencies, call 911. For a mental health crisis, call or text 988.