Care Clinic

Forms

For your convenience, listed below are all of the major forms used by the Care Clinic.

Referral Form - If you would like to make a referral to the Care Clinic, simply fill this out, and either fax it to us (410-706-3177) or email to our clinical aide (lblack@peds.umaryland.edu). Make sure to include your contact information on this, so that we can contact you for follow-up information.

Following the initial phone referral, you will be scheduled for a pre-intake session. During this session, you will be provided with a series o f questionnaires and consent forms. A few of these forms have been provided here. If you would like to speed things along, please print out the following forms, fill them out as best you can, and bring them to your first appointment.

Informed consent for treatment form for children - This form is to be signed by the parent(s) and child.
Adult Consent for Treatment - Informed consent for treatment form for adults.
Release of information form - Signing this release allows us to have contact with other professionals (e.g., doctors, therapists, social workers, teachers, etc.) and other people who might be able to share information about you/your child.
Child Form for parent - This form helps us in collecting background information about your child and your family.
Adult Intake Form - If you are an adult seeking services for yourself, please fill this out as much as possible to help us with background information

This page was last updated on: February 16, 2012.

For more information about UMCH or to make an appointment, please call 1-866-408-6885 (patients) or 1-800-373-4111 (physicians).