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Referral
How to Apply For Our Services
Include Assessment with it Please fax it to 410-779-9400 or email referral to info@newagepsychhealth.com
First Name
Last Name
Gender
Male
Female
D.O.B.
Guardian Name
Does the Parent/Guardian have legal custody (if minor)? Yes/No
Yes
No
Address
Phone
Email
Medical Assistance/Medicaid #
Is the individual eligible for full funding for Developmental Disabilities Administration services?
Yes
No
Have family or peer supports been successful in supporting this youth?
Yes
No
Is the primary reason for the youth's impairment due to an organic process of syndrome, intellectual disability, a neurodevelopmental disorder or neurocognitive disorder
Yes
No
ICD-IO Primary Diagnosis Code
Diagnosing Clinician and Title
Clinician Agency
Current frequency of treatment provided to this individual (At least Ix/week At least Ix/2 weeks At least Ix/month At least Ix/3months At least Ix/6months)
How long has youth been engaged in active, documented outpatient treatment? (Less than one month One visit in the last three months Two or more visits in the last three months)
Is the youth transitioning from an inpatient, day hospital or residential setting to the community setting?ngaged in active, documented outpatient treatment? (Less than one month One visit in the last three months Two or more visits in the last three months)
Yes
No
Does the youth have a Target Case Management referral or authorization?
Yes
No
Has medication been considered for this youth? Not considered Considered and Ruled Out Initiated and Withdrawn Ongoing (Other Comments):
Upload file if any
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