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Referral for CBHI Services
Date of Referral:
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Month
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Day
Year
Select one or more services for referral:
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Therapeutic Mentoring
Family Support and Training
In-Home Therapy
In-Home Behavioral Services
Intensive Care Coordination
Family-based Intensive Treatment
Other/Not Sure
Enter youth/client information
Youth/Client Full Legal Name:
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First Name
Last Name
Nickname/Chosen Name:
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Youth/Client Current Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB:
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Month
-
Day
Year
Age:
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Grade in School:
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Gender Identity (own words):
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Pronouns:
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Race/Ethnicity:
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Other:
Primary Language:
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Other Languages Spoken:
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School:
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Is Youth on IEP/504 Plan?
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Yes
No
Enter parent/caregiver information
Parent/Caretaker Name(s):
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Relationship to Youth:
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Primary Language:
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Other Languages Spoken:
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Who has the right to make medical and legal decisions for the Youth?
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Current Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address:
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Primary Phone:
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Format: (000) 000-0000.
Okay to leave a message?
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Yes
No
Secondary Phone:
Format: (000) 000-0000.
Okay to leave a message?
Yes
No
Enter referral information (if referral source is not parent/caregiver)
Referral Source Name:
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Agency:
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Phone Number:
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Format: (000) 000-0000.
Email Address:
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Relationship to Youth/Client:
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Is family aware of referral?
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Yes
No
Enter insurance and medical information
Primary Insurance:
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MassHealth/MMIS #:
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Subscriber Name:
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Subscriber ID:
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Primary Care Physician (PCP):
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PCP Phone:
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Secondary Insurance:
Subscriber Name:
Subscriber ID:
Medical Conditions/Allergies:
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Specify reason for referral
Provide a brief description of your goals, safety concerns, diagnosis, and/or other needs in making referral:
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Risk factors (e.g., DV, S/I, H/I, substance use, trauma, etc.):
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Strengths:
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Any of the following services in the last 30 days:
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Hospital
Community-Based Acute Treatment
Partial Hospitalization Program
Youth Community Crisis Stabilization
Youth Mobile Crisis Intervention
Other (please explain below)
Other:
Involvement with other providers:
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DCF
DMH
DYS
School
Other (please include below)
Other:
Service request
Therapeutic Mentoring (TM)
Therapeutic Mentoring (TM) pairs a youth with an adult mentor to help the youth build and improve their social, communi cation, and life needs. Typical frequency: Weekly sessions at home or in the community. Who can benefit: Youth who have moderate to severe behavioral health symptoms and who need support in the areas of problem-solving, social skills, communication, or conflict resolution. To receive TM, the youth also need to be receiving another behavioral health service (outpatient, IHT, IHBS, ICC or FIT).
Family Support and Training (FS&T)
Family Support and Training (FS&T) is caregiver support and coaching provided by a Family Partner (a professional who also has lived experience caring for youth with special needs). Typical frequency: 1–2 sessions per week that occur at home or in the community. Who can benefit: Caregivers who want to become more effective advocates for their child through understanding how to navigate systems and access community support. For caregivers to receive FS&T, the youth needs to be receiving another behavioral health service (outpatient, IHT, IHBS, or ICC).
In-Home Therapy (IHT)
In-Home Therapy (IHT) is intensive family therapy provided by a team of two behavioral health staff to help youth with social, emotional, or behavioral challenges. Typical frequency: 1–3 sessions per week that occur at home or in the community. Who can benefit: Families of youth with moderate to severe behavioral health symptoms who want help to resolve conflicts, learn new ways to talk to and understand each other, create new helpful routines, and find community resources.
In-Home Behavioral Services (IHBS)
In-Home Behavioral Services (IHBS) is behaviorally based therapy provided by a two-person behavioral health team that works directly with both the youth and the caregiver. Together, they develop a targeted behavior plan that the caregiver and youth can implement at home.– Typical frequency: 1–3 sessions per week that occur at home or in the community– Who can benefit: Youth whose behaviors are significant enough to interfere with their functioning at home or in the community
Intensive Care Coordination (ICC)
Intensive Care Coordination (ICC) is a care planning service for youth who have serious emotional and behavioral needs. ICC is delivered by a care coordinator, and is often provided with a Family Partner (FS&T described above). Typical frequency: Minimally 1 contact per week at home, in the community, or by phone. Who can benefit: Youth with serious behavioral health symptoms, including youth with co-occurring mental health and autism spectrum disorder, who need coordination across multiple services (mental health, state agency, special education, etc.). The care coordinator facilitates a team-based process including professionals and natural supports to create one plan.
Family-based Intensive Treatment (FIT)
Family-based Intensive Treatment (FIT) combines intensive family therapy, care coordination, and caregiver support for youth with serious behavioral and emotional needs. This service is delivered by a team of two behavioral health staff and a Family Partner (see FS&T above). Typical frequency: 3–5 sessions per week that occur at home or in the community. Who can benefit: Youth experiencing significant behavioral health symptoms, including co-occurring health and autism spectrum disorder, whose needs have required acute/urgent behavioral health services in the last 30 days such as a crisis evaluation or an out-of-home placement. The focus of this service is to stabilize the youth’s behavioral health needs, strengthen the family and community supports, and transition to outpatient therapy or IHT in 4–6 months.
Other
For Family Support and Training, and Therapeutic Mentoring:
A Comprehensive Assessment and CANS completed for the youth – PLEASE ATTACH
A Treatment Plan/Individualized Action Plan/Care Plan completed for the youth that includes a specific goal with objective outcome measures pertaining to the development of the parent/caregiver capacity to parent the youth in the home or community – PLEASE ATTACH
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