Referral Form – Request For Services

Instructions

Please fill in all the form fields as accurately as possible. If there is missing or incomplete information, it may cause a delay in processing your referral information.

You have two options to submit a referral to us.

  • It can be printed, completed and faxed to 410-220-0730.  ATTN: Ms. Wise

Click Here to Print

  • Fill in the form to the right and submit it through our secure website

For questions about completing this form or inquiries about our services please call 410-617-8026  x 0 or email essentialinfo@ebhsinc.com and a program representative will reply within 1 business day.







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Form

Request for Services

  • Client Information:

  •  

    Referral Signature:

    By signing below I am confirming my request that EBHS, Inc link the client listed above to one of their mental health service provider partners for individual mental health therapy. I understand that linkage to mental health therapy does not always guarantee enrollment in Adult Psychiatric Rehabilitation Programming.

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  • This field is for validation purposes and should be left unchanged.
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