Therapeutic Mentor (TM) Referral Form

Therapeutic Mentor (TM) Referral Form
Date of Referral:*

MonthDayYear
Date
Client's Legal name:*

First NameLast Name
Client's Affirmed Name:*
Client's Gender Identity:*

Man or Boy (CIS)Woman or Girl (CIS)Transgender Man or Boy/Trans Man/MasculineTransgender Woman or Girl/Trans Woman/FeminineGenderqueer/Gender Expansive/Nonbinary/Neither Exclusively Male nor Female
Client's Date of Birth:*

MonthDayYear
Date
Client's Age (3-21):*
Client's Primary Language:*
Client's Preferred Language:*
Would family be interested in the Multicultural Outreach Team? (Specialty clinical team focusing on multicultural youth and families - current language available is Spanish):*

YesNo
Would family be interested in the Pride Team? (Our inclusive PRIDE Team consists of highly qualified mental health professionals and paraprofessionals who are a part of the LGBTQIA+ community. Our PRIDE Team is thoughtful in our choice of respectful language, behaviors, and continued education to best reflect the current needs and expectations of the LGBTQIA+ community):*

YesNo
Insurance ID:*
Primary Insurance Type (NOTE: Family assistance is not accepted for MassHealth and Private Insurance TM Coverage ends at age 19):*

MassHealth - WellsenseMassHealth - TuftsMassHealth - MBHPBCBSTufts Health Plan (Commercial)Beacon (Commercial)Optum (Harvard Pilgrim)Optum (United Healthcare)Optum (UBH)Other
For Above Enter Other information and/or which BCBS State(i.e. BCBSRI, BCBSMA, etc.):
If able please upload a picture of the front and back of your insurance card

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Guardian's Name:*

First NameLast Name
Relationship to Client:*
Guardian's Phone Number:*
Please enter a valid phone number.
Guardian's Email:
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
DCF Worker Phone:
Please enter a valid phone number.
Please Specify if DCF Custody:

CRALegal
Referent Name:*

First NameLast Name
Referring Agency:*
Referent Phone:*
Please enter a valid phone number.
Referent Address:*

Street Address

Street Address Line 2

CityState / Province

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

YesNo
Has a TM referral been placed to another agency at the same time?*

YesNo
If yes, which agencies?
Has the client received TM services previously?*

YesNo
If yes, which agency?
Please list all Psychiatric Hospitalizations, Crisis Visits, or Risk Assessments that have occurred in the past (1) one year:*
Risk for Re-Hospitalization (1=very low, 3=moderate, 5=very likely)*

12345Other
*
Other Currrent Providers (CSA, Psychiatry, Individual Therapist, etc.). Include Name, Service, Agency and Phone Number:*
Reason for Referral/Goals: (symptoms, behavioral/social/emotional functioning of youth/family, focus of treatment. Please also include information regarding reasons this family/client would benefit from working with our Pride team):*
Medications (Name, Dose, Frequency, Indication):*
Family's Preference for Scheduling (Include days and times):*
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.
ICC Name:

First NameLast Name
ICC Phone:
Please enter a valid phone number.
ICC Agency:
Please complete the following steps at time of referral to ensure timely outreach:
IHT Name:

First NameLast Name
IHT Phone:
Please enter a valid phone number.
IHT Agency:
Outpatient Name:

First NameLast Name
Outpatient Phone:
Please enter a valid phone number.
Outpatient Agency:
File Upload for HUB Documentaiton:*

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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 SkillsDaily Living SkillsProblem Solving SkillsConflict ResolutionAnger Management SkillsBehavior Management SkillsSelf-Management Skills
At-Risk Factors or Safety Concerns Present (please choose all that apply):*

Suicidal IdeationsSuicidal GesturesSelf-Injurious BehaviorsHomicidal IdeationsCurrent Substance UseHistory of Substance UseRuns AwayViolence/Aggression towards OthersTakes Dangerous RisksSchool RefusalLack of Social GroupGang InvolvementIsolatesMed Compliance IssuesFire SettingHigh Risk Sexual ActivitySexualized Aggression and/or BehaviorsTrauma History (please explain below)Medical Physical Issues (please explain below)
Trauma History and Medical Physical Issues
Safety Concerns for Home-Based Team to Plan For (please choose all that apply):*

Unsafe NeighborhoodCurrent Domestic ViolenceViolent Family Member or Person Involved with FamilyLack of Safe Parking AvailableAnimals (please list below for Home allergies)Weapons in Home Involved with FamilySuspected Illegal Substances in HomeNone
Explain Safety Concerns Listed Above:
File Upload

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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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