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
*
Email
*
Service Referring For:
*
Intensive Care Coordination
In-Home Therapy
Family Partner*
Therapeutic Mentoring*
File Upload (pdf files only):
*
Browse Files
Drag and drop files here
Choose a file
HUB referral paperwork is only required if Intensive Care Coordination and/or In-Home Therapy are NOT selected.
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.
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.
Caregiver Name:
*
First Name
Last Name
Caregiver relationship to the youth:
*
Caregiver phone number:
*
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:
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
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?
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?
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: