PROGRAM REFERRAL

This document serves as the referral for behavioral health services for Momentum Health Management Services. Information collected here will be used to authorize the identified individual below. If you have questions or concerns about the requested information, please feel free to contact our office during business hours at (240) 539-2940 or send and email to info@momentum-cares.com.

"*" indicates required fields

Step 1 of 10

DEMOGRAPHIC INFORMATION

Who are your requesting services for?*

Consumer Name:*

First Last

Consumer Date of Birth:*

Parent/Guardian's Name:*

First Last

Contact Phone Number:*

Email:*

Preferred language:*

Living Situation:*

Address*

Street Address Address Line 2 City State ZIP Code

Insurance Type:*

MA#:

Social Security Number:*

Gender Identity:*

Are you currently pregnant?*

Ethnicity:*

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

Prefer Not to Say

Select all that apply.

Current Grade Level:*

School ID#:

School Name:

Highest Level of Education:*

Marital Status:*

Number of Dependent Children:*

Are you a veteran?*

Employment Status:*

Employer Name:

Are you a hurricane victim?*

Have you been arrested in the last 30 days?*

Primary Source of Income:*

Have you attended any self-help groups 30 days?*

Frequency*

Do you know the consumers Primary Care Physician's (PCP) information?*

Do you know the consumers Emergency Contact information?*

Is the referred currently receiving Mental Health Services?*

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name:*

First Last

Phone Number:*

Address:*

Street Address Address Line 2 City State ZIP Code

Email:

Relationship to Referred:*

SUD ENROLLMENT

This form is being filled at the consumers:*

Legal Status at Admission:*

How well does the Individual Speak English? (5 years old or older)*

Does the Individual Need Assistance with Communicating in English?*

Does the Individual Speak a Language other than English at Home?*

Did the Individual Attend School Any Time in the Past 3 Months?*

Is the Individual Deaf or hard of Hearing?*

Is the Individual Blind or Having Serious Difficulty Seeing, even when Wearing Glasses?*

Because of a Physical, Mental, or Emotional Condition, is the Individual having Serious Difficulty Concentrating, Remembering, or Making Decisions? (5 years old or older)*

Is the Individual Having Serious Difficulty Walking or Climbing Stairs? (5 years old or older)*

Is the Individual Having Difficulty Dressing or Bathing? (5 years old or older)*

Because of a Physical, Mental, or Emotional Condition, is the Individual Having Serious Difficulty doing Errands Alone such as Visiting a Doctor's Office or Shopping? (15 years old or older)*

Was the Individual Homeless in the Last 6 Months?*

Tobacco Use in the Past 30 Days*

Does the Individual Smoke Cigarettes?*

Was the individual screened for gambling?*

Confirmation of consumer's SUD History:*

Psych problem in addition to alcohol or drug:*

Primary Substance of Use:*

Age at First Use:*

Route of Administration:*

Frequency of Use:*

Date of Last Use:*

Signature with Credentials:*

Please attach documentation needed to support services for this consumer:

Drop files here or

Accepted file types: pdf, Max. file size: 512 MB.

(Ex: Treatment Plans, Assessments, Discharge Summaries, Court Order, etc.)

HIPAA AND PROGRAM DISCLAIMER

Protected Health Information: Momentum Cares understands that all protected health information (PHI) about you is personal and we are committed to protecting this information. We create a record of care and services you receive at this agency to provide you with quality care and to comply with certain legal requirements. This notice applies to all records about your care generated by Momentum Cares.

Md. Code, Health-General § 20-104: If you are 12 years of age or older, you have the same capacity as an adult to consent to consultation, diagnosis and treatment of a mental or emotional disorder by a physician, psychologist or a clinic.

[Md. Code Ann., Health-Gen. II § 20-102(c)(1)-(5)] Psychological treatment for drug abuse or alcoholism – A minor has the capacity to consent to psychological treatment for drug abuse or alcoholism if, in the judgment of the attending physician or a psychologist, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual.

Liability Waiver:*

I, hereby agree to release and hold harmless from any liability, Momentum Cares including its paid and volunteer staff executors, administrators, and other agents representing Momentum Cares. This waiver specifically relates to personal injury which may occur while participating in any programs or activity of any kind conducted, approved, organized, or sponsored by Momentum Cares or its representatives. Further, that the consideration for this waiver, is the right, privilege, and opportunity for myself/my child to participate in the programs and activities conducted, approved, organized, or sponsored by Momentum Cares.

Photo/Media Consent:

If I choose to consent and authorize Momentum Cares to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form). I authorize Momentum Cares to copyright the materials, and I authorize Momentum Cares to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to university publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I agree with these items to be used up to 99 years after the initial date of use. I agree that I am participating on a voluntary basis and I will not receive any payment from Momentum Cares for signing this release or as a result of any publication of the materials. If I choose to be photographed or recorded, I do not consent or authorize Momentum Cares to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).

Program Participation*

I give permission for myself/my youth to participate in Momentum Cares programming. I give permission for myself/my youth to hold conversations that discuss mental health, police brutality, healthy sex practices, positive peer relationships, and other topics that provide support and promotion for healthy development. (Md. Code, Health-General § 20-104) (If you are 12 years of age or older, you have the same capacity as an adult to consent to consultation, diagnosis and treatment of a mental or emotional disorder by a physician, psychologist or a clinic.) I do understand that there are some services that I will be eligible for and I agree to have MY INSURANCE BILLED for Case Management services.

PROGRAM REFERRAL

DEMOGRAPHIC INFORMATION

REFERS INFORMATION

PRIMARY CARE PHYSICIAN

EMERGENCY CONTACT INFORMATION

PRP ENROLLMENT

PRP PROVIDER INFORMATION

PRP ADOLESCENT INFORMATION

PRP Adult Information

OMHC ENROLLMENT

SUBSTANCE ABUSE INFORMATION

SUD ENROLLMENT

HIPAA AND PROGRAM DISCLAIMER

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