Baltimore Mental Health Systems, Inc.

APPLICATION FOR RESIDENTIAL REHABILITATION PROGAMS (revised 6/00)

This application is to be used for individuals requesting residential placement in Baltimore City. These services are coordinated by the Adult Services Team at Baltimore Mental Health Systems, Inc. (BMHS). Placements are in licensed Residential Rehabilitation Programs (RRP). The purpose of this application is to provide essential information needed to evaluate eligibility for services, and the level of care needed by the applicant. Services are available to adults (18 years or older) with priority given to Baltmore City residents with a severe and persistent mental illness. Upon receipt of the completed and signed application, the applicant will be referred to a program with a vacancy or place on a waiting list if no vacancy is available.

Please feel free to call Baltimore Mental Health Systems, Inc. at (410) 837-2647 with any questions or concerns. Please return the completed application and, if possible, a copy of the most recent psychsocial assessment or psychiatric evaluation to:

Adult Service Office

Baltimore Mental Health Systems, Inc.

201 E. Baltimore St., Suite 1340

Baltimore MD 21202

Fax: 410-837-2672