Maternal and Child Health Programs Referral

Please complete all relevant sections of the referral below. Once you submit, the form will be sent to Baltimore County’s Maternal Child Health Division, where a member of our care coordination team will follow up with you via phone, text or email. All information will be maintained confidentially to protect your privacy.

For questions, call 410-887-0249.

Your Information: Our team of care coordinators will use the information below to connect you with services and supports for you and your family. If you are completing the form for someone else, please enter their information below.

Please note that this referral may take up to 3 business days for our team to process. If you need contact more quickly please call us at 410-887-0249 or email at maternalchildhealth@baltimorecountymd.gov

Who are you completing this form for?

MyselfMy childSomeone else

Name*

First NameLast Name

Date of Birth*

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you live in Baltimore County? (This form is only available for Baltimore County residents.)*

YesNo

Phone Number*

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

What language do you speak?*

EnglishSpanishOther

Insurance*

Medical AssistanceUninsuredOther

Are you currently pregnant?

YesNo

Do you have a child under the age of 3?

YesNo

What is your estimated delivery date or EDC?

Date

Provide the name of your OB.

First NameLast Name

Provide the number of your OB.

Please enter a valid phone number.

Please list your known medical conditions.

What is your child's name?

First NameLast Name

What is your child's birthday?

Date

What is your child's sex?

Are you interested in any supportive services (i.e. mental health, food assistance, transportation, crib, etc.)?

What is the reason for your referral? (Examples: Health insurance, crib, WIC, home visiting programs, doula, pregnancy resources and information, etc.)

Your Referral Number