Therapeutic Mentoring (TM) Referral Form

Northeast Family Services

Therapeutic Mentoring (TM) Referral Form

Please complete all sections

Note that incomplete information may delay service delivery
Date of Referral: *

Month Day Year
Date
Youth Name: *

First Name Last Name
DOB: *

Month Day Year
Date
Known As:

First Name Last Name
MassHealth ID #: *
Language Required for Services: *
Sex: *

Female Male
Age (3-21): *
Indicate MassHealth Payer Type: **Family Assistance Not Accepted** *

MBHP Beacon (BMC, NHP, Fallon, Wellforce) Tufts Network Health
Guardian's Name: *

First Name Last Name
Relationship to youth: *
Guardian's Phone Number: *

Area Code Phone Number
Guardian's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent(s) Name if Different:
Members of the Household:
DCF Worker:

First Name Last Name
DCF Worker Phone Number:

Area Code Phone Number
Please Identify if DCF Custody is:

CRA Legal
Referent Name: *

First Name Last Name
Referring Agency: *
Referent Phone Number: *

Area Code Phone Number
Referent Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If ICC - Have the TM service units been authorized?

Yes No
Has a TM referral been placed to another agency at the same time? *

Yes No
If yes, which agencies?
Has the client received TM services previously? *

Yes No
If yes, which agency?
Please list all Psychiatric Hospitalizations, Crisis Visits, or Risk Assessments that have occurred in past (1) one year: *
Risk for Re-Hospitalization: (1=very low, 3=moderate, 5=very likely) *

1 2 3 4 5
Other Current Providers (CSA, Psychiatry, Individual Therapist, etc.):
Reason for Referral/Goals: (symptoms, behavioral/social/emotional functioning of youth/family, focus of treatment): *
Medications: Name Dose Frequency Indication *
Family's Preference for Scheduling: *

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Family's Preference for times: *
Clinical Hub Referral Source: (*Required at time of referral in order to obtain authorization and provide services to youth.)

TM is a Hub-Dependent service, which means the hub is responsible for including TM services on care/treatment plan, updating document quarterly, and maintaining a minimum of weekly phone contact with assigned TM.
ICC Name:

First Name Last Name
ICC Phone Number:

Area Code Phone Number
ICC Agency:
Please complete the following steps at time of referral to ensure timely outreach:
IHT Name:

First Name Last Name
IHT Phone Number:

Area Code Phone Number
IHT Agency:
Please complete the following steps at time of referral to ensure timely outreach:
Outpatient Name:

First Name Last Name
Outpatient Phone Number:

Area Code Phone Number
Outpatient Agency:
Please complete the following steps at time of referral to ensure timely outreach:
Please identify one or more of these skill building categories to be included on the updated treatment plan/care plan with descriptive goals that include TM interventions: *

Socialization Skills Daily Living Skills Problem Solving Skills Conflict Resolution Anger Management Skills Behavior Management Skills Self- Management Skills
At-Risk Factors or Safety Concerns Present (please check all that apply): *

Suicidal Ideations Suicidal Gestures Self-Injurious Behaviors Homicidal Ideations Current Substance Use History of Substance Abuse Runs Away Takes Dangerous Risk School Refusal Lack of Social Group Gang Involvement Med Compliance Issues Fire Setting Isolates High Risk Sexual Activity Sexualized Aggression and/or Behaviors Violence/Aggression Towards Others Trauma History, please explain below: Medical/Physical Issues, please explain below:
Please Explain any Trauma History:
Please Explain any Medical/Physical Issues:
Safety Concerns for Home-Based Team to Plan for (please check all that apply):

Unsafe Neighborhood Lack of Safe Parking Available Violent Family Member or Person Involved with Family Weapons in Home Suspected Illegal Substances in Home Animals
Please Describe any of the Safety Concerns for Home-Based Team to Plan for:
Upload any additional documents or forms to be submitted here:
To submit documents or forms via fax or mail

354 Merrimack St Suite 395

Lawrence, MA 01843

Fax: (774) 300-3207 or (774) 628-9657
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