CSA, IHT Online Referral Form
Date
*
-
Month
-
Day
Year
Is the parent/Caregiver aware of this referral
Please Select
No
Yes
Name of Person making referral:
*
First Name
Last Name
Is this a hub provider?
Please Select
No
Yes
Agency:
*
Role or relationship to youth:
*
Phone Number
*
Format: (000) 000-0000.
By checking this box, I consent to receive text messages related to appointment reminders, follow-up messages and billing inquiries from North Suffolk Community Services. You can reply "STOP" at any time to opt-out. Message and data rates may apply. Message frequency may vary, text HELP for assistance. Full Terms & Conditions may be found with our Privacy Policy.
Yes, I opt-in / agree to receive SMS / Text messages from NSCS.
Email
*
Service Referring For:
*
Intensive Care Coordination w/Family Partner
In-Home Therapy
Family-Based Intensive Treatment (FIT)
Family Partner*
Therapeutic Mentoring*
File Upload (pdf files only):
*
Browse Files
Drag and drop files here
Choose a file
Hub paperwork is required for standalone Therapeutic Mentor and/or Family Partner referrals.
Cancel
of
What is the name of the hospital or program?
*
Is the youth currently in DCF custody?
*
Please Select
No
Yes
If yes, please provide the name of the DCF worker
*
First Name
Last Name
If yes, Please provide the phone number of the DCF worker:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Youth’s Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Sex Assigned at Birth:
*
Please Select
Male
Female
Transgender
Language:
*
Youth Phone number if 18+:
Please enter a valid phone number.
Format: (000) 000-0000.
By checking this box, I consent to receive text messages related to appointment reminders, follow-up messages and billing inquiries from North Suffolk Community Services. You can reply "STOP" at any time to opt-out. Message and data rates may apply. Message frequency may vary, text HELP for assistance. Full Terms & Conditions may be found with our Privacy Policy.
Yes, I opt-in / agree to receive SMS / Text messages from NSCS.
Caregiver Name:
*
First Name
Last Name
Caregiver relationship to the youth:
*
Caregiver phone number:
*
Format: (000) 000-0000.
Caregiver Language preference:
*
Please Select
English
Spanish
Portuguese
Mandarin
French
Other
If “other” is selected, please fill in language:
*
Family street address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Referral (List any and all risk factors):
*
Include detailed information around presenting symptoms, relevant history and goals for requested services.
What is the youth’s school name:
What grade is the youth in?
School contact person name:
First Name
Last Name
School contact person phone number:
Format: (000) 000-0000.
Does the youth have an IEP?
Please Select
Yes
No
Unsure
Providers
Provider #1 name
First Name
Last Name
Provider #1 agency:
Provider #1 role:
Provider #1 phone
Format: (000) 000-0000.
Provider #1 email
What is the youth’s PCP’s name?
First Name
Last Name
What is the youth’s PCP’s agency?
What is the youth’s PCP’s phone number?
Format: (000) 000-0000.
What is the youth’s Prescriber name?
First Name
Last Name
What is the youth’s Prescriber agency?
What is the youth’s Prescriber phone number?
Format: (000) 000-0000.
List the youth’s current medications:
If none, please enter 'none'.
Describe any current or historical concerns around youth/family substance use:
*
If none, please enter 'none'.
Diagnosis (Primary diagnosis cannot be Autism, Global delay, Intellectual delay or medical diagnosis):
*
Insurance coverage?
*
Please Select
Mass Health Plan
Commercial insurance plan
Both
Mass Health plan insurance number:
*
Commercial insurance plan name:
*
(i.e- Blue Cross Blue Shield, Tufts, etc)
Commercial insurance plan number:
*
Name of subscriber:
First Name
Last Name
Date of birth of subscriber:
-
Month
-
Day
Year
Submit
Should be Empty: