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Referral for CBHI Services
Referral for CBHI Services:
*
Therapeutic Mentoring
In Home Therapy
Date of Referral:
*
-
Month
-
Day
Year
Youth’s Name:
*
First Name
Last Name
Preferred name:
Preferred pronoun:
DOB:
*
-
Month
-
Day
Year
Age:
*
Gender:
*
Parent/Caretaker Name(s):
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Work Phone:
Cell Phone:
Is family/guardian aware and in agreement with referral?
*
Yes
No
Has family been informed about what the service offers?
*
Yes
No
Who has authority to sign consents?
*
Referred by:
*
Agency:
*
Work Phone:
Email:
*
Care Coordinator/Hub Provider:
Agency:
Work Phone:
Email:
Reason for referral:
*
Has the referred youth (or his/her family) experienced a traumatic event(s):
*
Yes
No
If yes, describe:
Insurance Information
Choose Insurance:
*
Commercial Insurance
MassHealth Clients
Type of Insurance:
Insurance Number:
Responsible Party:
MassHealth #:
*please attach a copy of the insurance card
MCE coverage:
Medication:
Ethnicity:
*
Primary Language:
*
Religious Affiliation:
Diagnosis:
With whom does the youth currently reside?
*
Is the youth and/or family involved with any state agencies? (DCF, DMH, DYS, DDS, legal involvement)
*
Yes
No
If Yes, please list names and contact information. If No, put N/A
*
Goal(s) of service(s) to be provided?
Other Information:
To be included with referral:
Copy of care plan/treatment plan
Copy of CANS
Risk Management/Safety Plan (TM and CSA clients)
Comprehensive Assessment/Mental Status (TM only)
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