Therapeutic Mentor (TM) Referral Form

Therapeutic Mentor (TM) Referral Form - NEW 2021

Please Complete all pages. Note that incomplete information may delay service delivery.
Date of Referral: *

Month Day Year
Date
Youth's Legal name: *

First Name Last Name
Known As: *
Gender Identity: *

Female Male Transgender Other
Date of Birth: *

Month Day Year
Date
Age (3-21): *
Language Required for Services: *
Would family be interested in the Pride Team? (Specifically team for LGBTQ+ youth and families): *

Yes No
Primary Insurance Type: *
Insurance ID: *
Primary Insurance Type (NOTE: Family assistance is not accepted for MassHealth and Private Insurance TM Coverage ends at age 19): *

MassHealth - Beacon MassHealth - Tufts MassHealth - MBHP BCBS Tufts 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.):
Guardian's Name: *

First Name Last Name
Relationship to Youth: *
Guardian's Phone Number: *
Please enter a valid phone number.
Address: *

Street Address

Street Address Line 2

City State / Province

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

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

CRA Legal
Referent Name: *

First Name Last Name
Referring Agency: *
Referent Phone: *
Please enter a valid 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 the past (1) one year: *
Risk for Re-Hospitalization (1=very low, 3=moderate, 5=very likely) *

1 2 3 4 5 Other
*
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): *
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 mans the hub is responsible for including TM services on care/treatment plan, updating document quaretly and maintaining a minimum of weekly phone contact with assigned TM.
ICC Name:

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

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IHT Name:

First Name Last Name
IHT Phone:
Please enter a valid phone number.
IHT Agency:
File Upload

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Outpatient Name:

First Name Last Name
Outpatient Phone:
Please enter a valid phone number.
Outpatient Agency:
File Upload

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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 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 choose all that apply): *

Suicidal Ideations Suicidal Gestures Self-Injurious Behaviors Homicidal Ideations Current Substance Use History of Substance Use Runs Away Violence/Aggression towards Others Takes Dangerous Risks School Refusal Lack of Social Group Gang Involvement Isolates Med Compliance Issues Fire Setting High Risk Sexual Activity Sexualized Aggression and/or Behaviors Trauma 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 Neighborhood Current Domestic Violence Violent Family Member or Person Involved with Family Lack of Safe Parking Available Animals (please list below for Home allergies) Weapons in Home Involved with Family Suspected Illegal Substances in Home None
Explain Safety Concerns Listed Above:
File Upload

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If you have any questions: call (774) 206-1125 or our referral line directly at (978) 409-5855
Should be Empty:

Therapeutic Mentor (TM) Referral Form - NEW 2021