BESST Request for Services/Referral Form
Please provide some info below to help us learn how BESST may assist you. All information provided is secure and confidential. Once you have submitted this form, a BESST staff member will follow up by phone or email within 5-7 business days. IF YOU ARE HAVING A MEDICAL EMERGENCY, PLEASE CALL 911.
For any questions, please contact:
Lauri Murphy, MSW - BESST Coordinator
The Pettengill House, Inc.
Direct: (978) 243-9746 | Main Office: (978) 463-8801
Date of Birth
Primary Phone Number
Alternate Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Are you homeless/without permanent residence?
Do you have health insurance?
Please enter your health insurance provider and plan:
Area of assistance needed (please select all that apply)
Behavioral Health Services (counseling, medication, care coordination, etc.)
Family Support (you are concerned about a loved one and would like information and support)
MassHealth Application Assistance
Medical Provider (primary care or other health provider)
Senior Substance Use/Behavioral Health Support (age 60+)
SNAP Application Assistance
Substance/Alcohol Treatment or Recovery Support
Additional information regarding area of assistance requested:
How many members are in your household (including yourself)?
Please list the other members of your household:
Are you requesting assistance for yourself or someone else?
Someone else (please fill out the referral info below)
Referrer's Phone Number
Please enter a valid phone number.
Does the person you are referring know they are being referred?
Reason for Referral (please provide any pertinent information that prompted you to reach out on behalf of this person)
Should be Empty: