Refer Someone for Services

To refer yourself or someone else to the Care Clinic for services, please use our Client Profile Intake Form.

This link will take you to a HIPAA-compliant form that securely shares your information to our community outreach team.

Once you submit the form, our team will contact you to discuss your referral.

Learn more about eligibility for Care Clinic services.

Referral Information

Be sure to have the following information when completing this form:

• Name of the person(s) you wish to refer
• Date of birth
• Gender
• Race/ethnicity
• Contact information – phone, address, email, etc.
• Type(s) of abuse/neglect connected to the case
• Brief description of symptoms and other concerns 

Care Clinic Intake Form

If you have any questions or problems completing this form, please contact us as 410-706-4869.