Community Support Program Referral Form
Enrollee Name:
*
First Name
Last Name
Which service are you seeking? (Select one)
*
CSP
CSP JI (Justice Involved)
CSP HI (Chronically Homeless: Only select if individual has a permanent supportive housing opportunity and will move in within 120 days)
Date
*
-
Month
-
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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Yes, I opt-in / agree to receive SMS / Text messages from NSCS.
Date of Birth:
*
-
Month
-
Day
Year
Sex Assigned at Birth:
*
Please Select
Male
Female
Transgender
Gender Identity:
*
Please Select
Identifies as Male
Identifies as Female
Female-to-Male (FTM)/Transgender Male/Trans Man
Male-to-Female (MTF)/Transgender Female/Trans Woman
Genderqueer, neither exclusively male nor female
Choose not to disclose
Additional gender category or other, please specify
Gender Identity other:
*
Sexual Orientation:
*
Please Select
Lesbian or gay
Straight or heterosexual
Bisexual
Don't know
Choose not to disclose
N/A
Something else, please describe
Sexual Orientation Other:
*
Pronouns:
*
Please Select
She/Her
He/His
They/Theirs
Ze/Zir
Other
Soc Sec No.:
*
Ethnicity:
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Decline to Specify
Race:
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Declined to Specify
Cultural background:
*
(Arabic, Haitian, Salvadorian, etc.)
Language
*
Marital Status:
Emergency Contact Name:
First Name
Last Name
Emergency Contact #:
Please enter a valid phone number.
Where is enrollee now?
*
Referred By:
*
First Name
Last Name
Agency:
*
Phone number:
*
Outpatient Therapist name
First Name
Last Name
Outpatient Therapist phone
Legal Representation name
First Name
Last Name
Legal Representation phone
Clinical Information
History of trauma
*
Yes
No
Substance abuse
*
Yes
No
Length of sobriety
*
History of harm to others or self
*
Yes
No
Currently inpatient/Discharge from inpatient/detox facility with the last 6 months?)
*
Yes
No
History of treatment:
History of Medications:
History of substance abuse:
High Risk Behaviors:
*
CSP Goals:
*
Summary/Reason for Referral:
*
(Please include the consumer’s barriers in reaching their goals)
Diagnosis:
Diagnosis code:
File Upload (pdf files only):
Browse Files
Drag and drop files here
Choose a file
Upload biopsychosocial/relevant assessment/summary
Cancel
of
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
Is this a Project North referral?
Yes
No
Date of Service (Please input date (mm/dd/yyyy)
Individual (Non-PII identifier) ID
Name of Insurance Plan
Under Parole Supervision?
Yes
No
Prefer Not To Say
On Probation?
Yes, Pretrial
Yes, Sentenced
No
Prefer Not To Say
Have you been involved in any court process during the past year?
Yes
No
If yes, which court department(s)? (Select all that apply)
Boston Municipal Court
District Court
Superior Court
Juvenile Court
Probate and Family Court
Housing Court
Current open case with the court?
No
Yes, Boston Municipal Court
Yes, District Court
Yes, Superior Court
Yes, Juvenile Court
Yes, Probate and Family Court
Yes, Housing Court
Current case involves specialty court?
Yes
No
Referral source
Have you ever been incarcerated?
Yes
No
Submit
Should be Empty: