How to make a referral: Please contact our office secretary and you will be prompted to complete an initial screening intake. This form includes reported demographic information and presenting problems. You can also print out the attached intake form and send to our office to begin the referral process. Once this information is obtained, insurance verification will occur and authorization will be requested from your insurance company. The secretary will promptly contact you to schedule an intake appointment with one of our licensed therapists in the office.
Please bring the following documents to your initial appointment:
- Birth Certificate
- Social Security Card
- Medical Insurance Card
- Copy of recent physical examination
- Copy of immunization records
**These documents are required per the State of Maryland Department of Mental Health and Hygiene requirements**
If you are interested in services, please contact the intake coordinator at the Wicomico or Somerset offices.
Irene Thomas at Wicomico County Clinic 410-677-0202
Renee Carlins at Somerset Clinic 410-968-3547
Renee Carlins at Somerset Clinic 410-968-3547
OMHC
Respite
- RespiteReferralFY2017.pdf
- /userfiles/1526357/file/RespiteReferralFY2017.pdf
PRP
MHVP
MHVP Referral Form 2017
https://docs.google.com/a/
Discounted Fee Scale
Maple Shade Youth and Family Services use a discounted/sliding fee schedule to ensure that non one who is unable to pay will be denied access to services.
Please see the front office staff for an application and the requirements for this program.
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