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TEAM OF EXPERTS

PERSONALIZED TREATMENT PLANS

CONVENIENT CARE

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Place a Referral

Date of Referral:

Client's Information

Client's Name:

D.O.B

Social Security Number:

Address:

City:

State:

Zip:

Daytime Number

Home/Other:

Race:

Ethnicity:

Marital Status:

Gender:

Insurance Type:

Medicaid #:

Authorized:

Yes
No

Legal Guardian:

Are you the birth parent:

Yes
No

IMPORTANT: A LEAGAL DOCUMENT MUST BE PRESENTED AT TIME OF INTAKE TO SHOW GUARDIANSHIP:

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Court
DSS

Legal Guardian:

Relationship to Minor:

Legal Guardian Address:

Zip:

Referral Source:

Therapist Name:

Phone:

Fax:

Agency Name:

Email Address: *

Address:

City:

State:

Zip:

Primary Care Provider:

Facility’s Name

Doctor’s Name:

Phone

Address:

City:

State:

Zip:

Email:

Info@AmericanPsychiatricGroup.com

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CONTACT

Email: Info@AmericanPsychiatricGroup.com

Columbia Office:

10632 Little Patuxent Pkwy #104 Columbia, MD 21046

Phone Number: (410)-599-9977

Baltimore Office:

17 E Franklin Street Baltimore, MD 21202

Phone Number: (410) 600-3500

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