MST Referral MST Referral Please fill out the form below and our team will respond in a timely manner. Exclusions Please review the exclusions below before completing the referral form. Youth living independently, or youth for whom a primary caregiver cannot be identified despite extensive efforts to locate all extended family, adult friends, and other potential surrogate caregivers. Youth referred primarily due to concerns related to suicidal, homicidal, or psychotic behaviors. Youths whose psychiatric problems are the primary reason leading to referral, or who have severe and serious psychiatric problems. Juvenile sex offenders (sex offending in the absence of other delinquent or antisocial behavior). Youth with moderate to severe difficulties with social communication, social interaction, and repetitive behaviors, which may be captured by a diagnosis of autism. Referral IDThis field is hidden when viewing the formInstitute Case IDReferral Date(Required) MM slash DD slash YYYY This field is hidden when viewing the formReferral & Service InformationReferral Source Type(Required)Select BelowDJS Baltimore CITYDJS Baltimore COUNTYBaltimore City School CourtSelect the type of organization or individual making the referralReferral Source(Required) First Last Referral Source Phone(Required)Referral Source Email(Required) DJS Case Management Specialist (First and Last Name)(Required)DJS ASSIST Number (TYPE NA IF YOU DONT HAVE IT)(Required)DSS Case Worker (First and Last Name)(Required)DSS CJAMS Number (TYPE I DONT HAVE IT IF YOU DON'T HAVE IT)(Required)Please specify other referral source typeDepartment of Juvenile Services (DJS) Involvement Level(Required) Intake/Pre-Court Probation Aftercare/Reentry Adjudicated Delinquent Under Adult Probation Exhibits Aggressive or Assaultive Behavior If the youth is involved with DJS, select their current statusDepartment of Social Services (DSS) Involvement LevelSelect BelowCPS – InvestigationCPS – Alternative ResponseFamily PreservationFoster CareNo DSS InvolvementIf the youth is involved with DSS, select their current statusYOUTH DEMOGRAPHICSDate of Birth (Age 12-17)(Required) MM slash DD slash YYYY Youth Name(Required) First Middle Last Suffix Gender(Required)Select BelowBoyGirlNon-binaryTransgender BoyTransgender GirlEthnicity (Hispanic or Latino Origin)(Required)Select BelowNoYesUnknownRace(Required)Select BelowAfrican American/BlackAmerican Indian or Alaska NativeAsianBiracial/MultiracialNative Hawaiian/Pacific IslanderOtherWhiteUnknownCounty of Residence(Required)Select BelowAllegany CountyAnne Arundel CountyBaltimore CountyCalvert CountyCaroline CountyCarroll CountyCecil CountyCharles CountyDorchester CountyFrederick CountyGarrett CountyHarford CountyHoward CountyKent CountyMontgomery CountyPrince George’s CountyQueen Anne’s CountySt. Mary’s CountySomerset CountyTalbot CountyWashington CountyWicomico CountyWorcester CountyBaltimore CityCONTACT INFORMATIONAddress(Required) Street Address Address Line 2 City ZIP Code TelEmail School(Required)Grade(Required)LEGAL STATUS & KEY PARTICIPANTSLegal Status(Required) Community Pending release Court Mandated Other Key Participants(Required) Referral Source Parent/Guardian/Caregiver Household member names Probation Officer MH Worker Social Services/ Care Worker Probation Officer Name(Required) First Last Probation Officer Phone(Required)Probation Officer Email(Required) MH Worker Name First Last MH Worker PhoneMH Worker Email Social Services/ Care Worker(Required) First Last Social Services/ Care Worker Phone(Required)Social Services/ Care Worker Email(Required) Household Member Names(Required)First NameLast Name Add RemoveHit the blue plus button to add more membersGuardian Name(Required) First Last Guardian Email(Required) Guardian Telephone #(Required)COMPLETE FIELD INVENTORY(Required) Anxiety disorder Diagnosed with ADHD Autism spectrum disorder Blind or visually Chronic offender Chronic physical condition (managed) Chronic physical condition (unmanaged) Co-occurring: Mental health + intellectual/developmental Co-occurring: Mental health + substance use Co-occurring: Mental health + medical condition Conduct disorder Deaf or hard of hearing Depression or mood disorder Drug-related criminal offense Eating disorder Domestic and/or community violence Fetal alcohol syndrome Fire-setting behavior (history, not current) Fire-setting behavior (recent/active) First-time or misdemeanor offender Frequent property destruction Gang-involved High school graduate or GED Runaway or AWOL behavior (history) Homeless or housing unstable Homicidal ideation Learning or communication disorder LGBTQ Medically fragile Mild intellectual disability Moderate intellectual disability Oppositional defiant disorder (ODD) Personality disorder Post-traumatic stress disorder (PTSD) Pregnant Reactive attachment disorder (history) Self-harm or self-injurious behavior Serious emotional disorder (SED) or serious mental illness (SMI) Severe intellectual disability Adjudicated delinquent Under adult probation Aggressive or assaultive behavior Sexual behavior problems (not adjudicated) Adjudicated sexual offender Substance use disorder Suicidal ideation Teen parent/caregiver Truant or dropout Victim of child abuse, maltreatment, or neglect Victim of human trafficking or commercial exploitation Violent offender Adjudicated Delinquent – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s adjudicated delinquent status (e.g., court order, probation records)Under Adult Probation – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s adult probation status (e.g., probation order, probation officer contact information)Autism Spectrum Disorder – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s autism spectrum disorder diagnosis (e.g., psychological evaluation, medical records)Co-Occurring Mental Health and Intellectual/Developmental Disorders – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s co-occurring mental health and intellectual/developmental disorders (e.g., psychological evaluation, IEP, medical records)Co-Occurring Mental Health Disorders and Medical Conditions – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB, Max. files: 1. Please upload documentation verifying the youth’s co-occurring mental health disorders and medical conditions (e.g., psychological evaluation, medical records)Gang-Involved – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s gang involvement (e.g., police reports, gang assessment, probation records)Mild Intellectual Disability – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s mild intellectual disability diagnosis (e.g., psychological evaluation, IEP, IQ testing results)Moderate Intellectual Disability – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s moderate intellectual disability diagnosis (e.g., psychological evaluation, IEP, IQ testing results)Sexual Behavior Problem – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s sexual behavior problems (e.g., psychological evaluation, treatment records)Sexual Offender – Supporting Documentation(Required) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. Please upload documentation verifying the youth’s adjudicated sexual offender status (e.g., court order, sex offender registry documentation)Youth Behavioral Characteristics & EligibilityOther Youth Behavioral CharacteristicsYouth-School Characteristics(Required) Expelled or dropped out of formal education Attending alternative school setting – not mainstream Multiple suspensions for problem behavior High association with antisocial school peers Low affiliation with prosocial school peers Poor relationships with school staff Attendance problems Academic problems – risk of failure N/A Other (please specify) Please specify other school characteristics(Required)Youth-Peer Characteristics Gang membership or strong affiliation High affiliation with mostly antisocial peer Mixed antisocial and prosocial peers Low affiliation with prosocial peers Other (please specify) Please specify other peer characteristicsDesired Outcomes for referral to MST services. Please place checkmark in other target areas.(Required) Prevent out of home placement Improve family problem solving skills Reduce aggressive and/or criminal behaviors Improve family communication and cohesiveness Retain in school/vocational efforts and/or improve school attendance Improve family behavioral management skills Improve academic functioning Improve youth pro-social involvement and peer relationships Reduce substance use Other Desired Outcomes for referral to MST services. Please place checkmark in other target areas.PLEASE ATTACH THE FOLLOWING IN YOUR REFERRAL PACKET IF AVAILABLE(Required) Summary of Prior Offending Recent Mental Health Evaluation Recent Educational Evaluation Other Other (Explain)Attachment Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB. This field is hidden when viewing the formDisposition Decision (To be Completed by MST Program Staff):(Required) Accepted for MST Program Family Signed Agreement to Participate Not Accepted Inappropriate for MST Program Service Not Available Other Reason This field is hidden when viewing the formDate Services Initiated(Required) MM slash DD slash YYYY This field is hidden when viewing the formOther Disposition Decision (To be Completed by MST Program Staff):(Required)This field is hidden when viewing the formOLD FIELD – Referral Source Type(Required)Select BelowDepartment of Juvenile ServicesDepartment of Social ServicesCourtCrisis Response ProgramHospitalInternal AgencyMental Health Agency/ProviderParent/CaregiverPoliceSchoolTruancy CourtOther (specify)Select the type of organization or individual making the referralThis field is hidden when viewing the formOLD – Department of Juvenile Services (DJS) Involvement Level(Required)Select BelowIntake/Pre-CourtProbationAftercare/ReentryAdjudicated DelinquentUnder Adult ProbationExhibits Aggressive or Assaultive BehaviorIf the youth is involved with DJS, select their current status
