Substance Use Services Referral Form
Including Medication Management
Date of Referral:
*
-
Month
-
Day
Year
Date
Client's Legal Name:
*
First Name
Last Name
Client's Affirmed Name:
*
Client's Date of Birth:
*
-
Month
-
Day
Year
Date
Client's Social Security Number:
Gender Identity:
*
Man (Cis)
Woman (Cis)
Transgender Man or Trans Man/Masculine
Transgender Woman or Trans Woman/Feminine
Genderqueer/Gender Expansive/Nonbinary/Neither exclusively male nor female
Scheduling Preference (Day and Time of Day); Telehealth Services for Medication Management may be Available:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Mornings
Afternoons
Early Evenings
Programs:
Individual Therapy
Medication Assisted Treatment (MAT)
Intensive Outpatient (IOP)
Recovery Coach
Group Therapy
Language Needed for Service:
*
Do you have an Therapist gender preference?
*
Woman
Man
Trans/Genderqueer/Non-binary
No Preference
Do you have a preferred Therapist/Clinician you would like to see? Please provide their name:
Client/Guardian Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client/Guardian Name:
*
First Name
Last Name
Client/Guardian Phone Number:
*
Please enter a valid phone number.
Client/Guardian Email:
example@example.com
Guardian's Preferred Language:
Need for Medication Management Services
*
Yes
No
If Yes, Please Explain:
Insurance ID:
*
Primary Insurance Type:
*
MassHealth - Massachusetts Behavioral Health Partnership (MBHP)
MassHealth - BeHealthy Partnership (MA MBHP Health New England)
MassHealth - Beacon BMC Healthnet Plan Southcoast Alliance
MassHealth - Beacon BMCHP QHP ConnectorCare Plan 1, 2 and 3
MassHealth - Beacon Fallon 365 Care
MassHealth - Beacon Wellforce Care Plan
MassHealth - Tufts Health Direct ConnectorCare I
MassHealth - Optum My Care Family (MA Allways Health Partners MCD)
Commercial - Blue Cross Blue Shield of MA
Commercial - Blue Cross Blue Shield Anthem
Commercial - Harvard Pilgrim (United Behavioral Health)
Commercial - Optum United Health Care
Commercial - Optum Allways Health Partners
Commercial - Tufts
Commercial - Fallon Health Care
If able please upload a picture of the front and back of your insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Policy Holder:
First Name
Last Name
Policy Holder Date of Birth:
-
Month
-
Day
Year
Date
Policy Holder Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder Cell Number:
Please enter a valid phone number.
Policy Holder Home Number:
Please enter a valid phone number.
Policy Holder Work Number:
Please enter a valid phone number.
Referred By:
First Name
Last Name
Referent Phone Number:
Please enter a valid phone number.
Referent Agency:
Referent Email:
example@example.com
Clinical Information:
Diagnosis/Diagnoses:
Current Safety Concerns (SI/HI/Overdose Risk):
Immediate Need for Basic Necessities:
Current Substance Use:
*
Current physical/social/psychological Needs:
Presenting Problem/Issue:
*
Submit
Should be Empty: