Mental Health Case Management (YOUTH) Mental Health Case Management Referral (YOUTH) Referral Date MM slash DD slash YYYY JurisdictionCaroline CountyDorchester CountyKent CountyQueen Anne's CountySomerset CountyTalbot CountyWicomico CountyWorcester CountyName of Person Being Referred(Required) First Last Gender and preferred pronoun(Required) Race(Required) Is the person being referred under 18?(Required) Yes No Date of Birth(Required) MM slash DD slash YYYY Phone Number of Person Being Referred(Required)Address (if known) Street Address Apt/Unit/Suite/Floor City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best way to contact Name of Guardian (if applicable)(Required) First Last Phone Number of Guardian(Required)Email Best way to contact Is the person being referred privately insured?(Required) Yes No If privately insured, name of insurance and ID if known. If no, Medicaid number if known. Reason for the referralREFERRAL SOURCEName of Person Making Referral(Required) First Last Phone Number of Person Making Referral(Required)Email of Person Making Referral Enter Email Confirm Email Consent to Proceed By checking this box, I confirm that I understand that I am applying for Care Coordination. This service has been explained to me and I understand that if approved I will participate in development of a Plan of Care with a team of people working with my family. I authorize the release of information to Wraparound Maryland, Inc. so they can conduct a full screening and initiate an eligibility determination by the Administrative Service Organization (ASO) to determine my eligibility for Care Coordination services. I understand that I may revoke my permission at any time by written or verbal request.