Community Support Program Referral Form
Enrollee Name:
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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
Submit
Should be Empty: