BCNC Referral Form

Referral for Short-term Mental Health Counseling Services
For mental health and/or substance use disorder crisis, please call 911 for immediate assistance.

If you have any enquiries about the our services, the application procedures and related matters, please email Kit Yung, Director of Family Services or call 617-249-2995 ext. 1065.

If you are seeking to refer yourself for services, please use the self-referral form.
REFERRAL INFORMATION
Relationship with Client*

Service ProviderParent/Legal Guardian
Name of Referrer *
Referring Agency *
Title of Referrer *
Phone
Email
example@example.com

AUTHORIZATION AND ACKNOWLEDGEMENTS
Does the client authorize BCNC to communicate the referral status to the referring provider?*

Yes, Client authorizes.No, Client does not authorize.
SIGNATURE
Name of Person Making Referral *
Signature of Person Making Referral *

Clear
Date of Referral *

MonthDayYear
Should be Empty:

Referral for Short-term Mental Health Counseling Services