<p> Life Renewal Services St. Agnes Medical Center 3455 Wilkens Avenue, Ste. 303, Baltimore, MD 21119 Office (410) 525-1105 Fax (410) 525-1106</p><p>Date: _____/_____/_____ Referral Form Demographics Last Name: First Name: DOB: Sex: F M Address: City: State: Zip: OK to Leave Message? □ YES □ NO Phone (1): Phone (2): SSN: Race: Email Address: School Attending: Current/Highest Grade Completed: Marital Status: Resides with: Parent/Guardian: Relationship: ** Please Note: Service cannot begin unless proof of custody is provided** Referral Referred By: ______school ______hospital ______friend ______self-referral ______other Name of Caller: Phone number: Reason for referral: Primary: (Primary reason for referral must be Mental Other Health) Suicidal Ideations: Past: Y N Current: Y N Homicidal Ideations: Past: Y N Current: Y N **Please forward copies of latest physical, immunization records and custody papers, if legal guardian is not the biological parent. ** Medical Information PCP & Location: Phone #:</p><p>Current Physical ______YES; if Yes, Date: ______(In the last 12 Months) ______NO (Proof of physical must be present at the time of initial Evaluation) Current Psychiatric DX/ TX/ Medication:</p><p>Prior Psychiatric DX/TX/ Medication:</p><p>Drug/Alcohol Use:</p><p>Current/Pending Legal Issues:</p><p>Insurance Information Employment Status: Primary: MA#:</p><p>Initial Evaluation Date: Time: Reschedduled: Y N New Date: (2): New Time (2): **If hospital referral – Appointment within 5 business days; all others within 14 business days** Comments</p><p>Print Name: Signature: LIFE RENEWAL SERVICES Behavioral Health Center Admission Screening</p><p>Client’s Name: </p><p>Client’s DOB: Date of Screen: </p><p>Name and Credentials of Mental Health Professional:</p><p>______Name/Title I. APPROPRIATENESS OF REFERRAL</p><p>______A. This is an appropriate referral to the LRS Clinic.</p><p>______B. The referral is not appropriate. The individual was referred to the following agency: </p><p>______C. Priority for OMHC services is:</p><p>______High (suicidal/homicidal ideations, recent hospitalizations, any other emergencies that warrant evaluations per evaluator’s assessment) Note: Schedule within 5 business days of referral.</p><p>______Low (no emergent issues according to evaluator’s assessment, client stable – has available resources and supports to maintain stability until next appointment) Note: Schedule within 14 business days of referral.</p><p>Client’s Goals for Recovery: </p><p>Client’s Strengths: </p><p>Client’s Needs (urgent or critical needs identified): </p><p>Clients Abilities: </p><p>Client’s Preferences (Do you have a preference to how services are delivered): </p><p>Signature of Professional: ______</p><p>Date: ______</p>