• Therapeutic Mentor (TM) Referral Form

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  • Clinical Hub Referral Source: (*Required at time of refferal 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 (as a goal), updating document quarterly and maintaining a minimum of weekly phone contact with assigned TM.

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  • If you have any questions or issues submitting this form:  call our referral line directly at (978) 409-5855.

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