Refer | Right Step Baltimore

Use this form to send direct referrals for Outpatient Substance Abuse Treatment, Intensive Outpatient Treatment, and Psychiatric Rehab Services for Adults.

Rerral Type (select all that applies)

Outpatient Substance Abuse Treatment (less than 9 hours of service weekly)

Intensive Outpatient Treatment (9 or more hours of service weekly)

Adult Psychiatric Rehabilitation Services - PRP (6 therapeutic encounters monthly)

Mental Health Therapy

If selecting PRP, indicate the track you would like to start with:

Reentry - Community engagement and access to resources

Vocation - Economic management and stability

Personal Development - Coping with mental illness in the community

Housing - Linkage to resources and housing stability

Client Name

Client DOB

Client Email

Client Phone

Referral Source - Provider/Agency Name: (if self referring, write "self")

Referral Source - Contact Number (if self referring, write N/A)

Referral Source - Email Address (if self referring, write N/A)

ICD 10 Diagnosis Code: (Required for PRP referrals)

Reason for Referral (include frequency and severity of the problem)

Referring Provider/Agency Staff Signature (Include Credentials and Date): By typing in your name and date below, you agree that your are the party listed as the referral source and are electronically endorsing the information provided in this referral for the purpose of Outpatient, Intensive Outpatient, or PRP services.

Thanks for the referral. We will be reaching out soon!