CLINIC (BHC)

Referral for Behavioral Health Clinic Services
Individual TherapyFamily TherapyMedication Management/Psychiatry
*Medication Management/Psychiatry services can only be received in conjunction with a therapy modality.
Clinic BasedSchool Based
School Attending
Date of Referral: *

MonthDayYear
Youth’s Name:*

First NameLast Name
Preferred Name:
Preferred pronoun:
DOB:*

MonthDayYear
Age:*
Gender:*
Parent/Caretaker Name(s):*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email Address:
Best time to contact family:*
Availability for therapy sessions, list days & times:*
Legal Guardian (if different than above):
Phone:
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email Address:
Who has authority to sign consents?*
YesNo
YesNo
Referred by:
Agency:
Phone:
Format: (000) 000-0000.
Email:
Reason for referral:*
YesNo
If yes, describe:
Primary Care Physician:
Phone:
Format: (000) 000-0000.
Medication:
Prescriber:
Psychiatrist if applicable:
HispanicNon HispanicPrefer not to disclose
WhiteAsianBlack or African AmericanMulti RacialPrefer not to disclose
Primary Language:*
Religious Affiliation:
Diagnosis:
With whom does the youth currently reside?*
YesNo
If Yes, please list names and contact information.
Other Information:
Payment Source
Commercial InsuranceMassHealth Clients
Type of Insurance:
Insurance Number:
Responsible Party:
MassHealth #:
*please attach a copy of the insurance card
MCE coverage:
Should be Empty:

Referral for Behavioral Health Clinic Services

Payment Source