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About
Programs
Admissions
Staff
Referrals
FAQ
Contact

Speak To A Human

Referrals Form

Provider Referral Form

Please complete all required fields. *

Referrer Information

Your Full Name *

Facility / Organization *

Phone Number *

Email Address *

Patient Information

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Reason for Referral

Presenting Problem *

0/800

Recommended Level of Care * PHP IOP Unsure / Seeking Recommendation

Substance Use & Mental Health Dx

Primary Substance of Concern *

If “Other,” please specify *

Mental Health Diagnoses *

Select all that apply.

Depression Anxiety ADHD PTSD Bipolar Disorder Psychotic Disorder Borderline Personality Disorder Unknown / Not Assessed Other

If “Other,” please specify *

Insurance & Housing

Insurance Provider (optional)

If “Other,” please specify *

Does the patient need housing support? (optional) Yes No Unsure

Medical Information & MAT

Is the patient currently on any medication assisted treatment? (MAT) *

If “Yes”, please specify medication *

Current Medications *

0/800

Biomedical / Medical Concerns *

0/800

All information is confidential and protected by HIPAA.

Thank you for reaching out.

Thanks for submitting. Someone from our admissions team will reach out to you shortly.

Where to find us.

410.970.4842
admissions@glasshouserecovery.com
8318 Forrest St, Suite 100 Ellicott City, MD 21043
Hours of operation: Mon-Fri 9am-5pm

If you need crisis assistance outside of our current operating hours, call 911 (for true emergencies), contact 211, your local crisis response team, or go to the nearest emergency room.

Let's talk about how we can help.

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Comments/Questions

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