Type of care being requested (select preferred services)
*
Intensive Care Coordination (ICC)
Intensive In-Home Family Therapy (IHT)
Family Support & Training (FST)
Therapeutic Mentoring (TM)
Family Intensive Treatment (FIT) For FIT referrals on the weekend & holidays ONLY, please contact the on-call at 617-471-8400. Please note - FIT services may require daily meetings with your care team.
Unsure
Referral Date
-
Month
-
Day
Year
Date
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Youth's Information
Youth's Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date of Birth
Gender
*
Male
Female
Transgender Male
Transgender Female
Other
Preferred Pronoun
*
He
She
They
Other
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it okay to leave a message?
*
Yes
No
Ethnicity
*
Hispanic
Non-Hispanic
Ethnicity
*
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Multi-ethnicities
Unknown/Not specified
Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Multi-racial
Unknown/Not specified
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Parent/Legal Guardian Information
Parent/Legal Guardian Name
*
First Name
Last Name
Parent/Legal Guardian Relationship
*
Parent/Legal Guardian Email
*
example@example.com
Parent/Legal Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it okay to leave a message?
*
Yes
No
Custody Information (Please explain)
*
Does family agree to services?
*
Yes
No
Has the youth been served by Bay State Community Services in the past?
*
Yes
No
Uncertain
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Referral Information
Referred by (If parent or guardian, please provide their name)
*
First Name
Last Name
Title
*
Agency (if parent or guardian, please list n/a)
*
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source Email (if parent or guardian, please provide your email)
*
example@example.com
If referred from a 24-hour facility or ESP, select the date of evaluation/discharge
-
Month
-
Day
Year
Date
If referred from a 24-hour facility or ESP please upload an evaluation and or discharge note
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Is the youth in a dangerous situation?
*
Yes
No
Uncertain
If yes, please explain.
Primary language in the home
*
Special communication needs?
*
Sign Language Interpreter needed
Language Interpreter Services
TDD/TYY
Assistive Listening Device(s)
None
Other
If other, please explain.
Primary Insurance
*
Subscriber
*
Primary Insurance Policy Number
*
Secondary Insurance
Subscriber
Secondary Insurance Policy Number
Primary Diagnosis Required
*
Diagnosis Code (if unknown, please list n/a)
Primary Care Physician/Pediatrician
Primary Care Physician's role (if unknown or none please list n/a)
*
(PCP, etc.)
Primary Care Physician/Pediatrician's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is Youth involved with other providers (i.e., School, Outpatient, DCF, DMH, etc.)?
*
Yes
No
Uncertain
If yes, please list the Name, Title, Agency, & Phone Number below for each provider. (respond N/A if not applicable)
*
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Reason for referral: What are your family's/the family's specific needs you/they may have? How might you/the child's caretaker(s) benefit from services provided? What are the examples of behaviors and symptoms that make the child meet this level of care? Has this child met with Crisis Team, attended Partial Hospitalization, CBAT, and/or IP level of care? If so, when and where?
*
Please share your family's/the family's identified strengths and goals?
*
Are there any scheduling concerns? (examples: Cannot meet between 9 AM and 5 PM, Not able to meet on Monday's) Any animals in the home? If yes, please explain or include N/A if not applicable.
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For Providers:
Therapeutic Mentoring (TM) Assessed Needs Checklist: (TM) Goals (for other skills be as specific as possible)
Basic/Beginning Social Skills
Advanced Social Skills
Dealing with Feelings
Alternatives to Anger/Anger Management Skills
Self-Management/Stress Management Skills
Problem Solving/Conflict Resolution Skills
Daily Living/Community Management Skills
None
Uncertain
Other
If Other was selected, please be as specific as possible.
Family Support & Training (FST) Assessed Needs Checklist: (FST) Goals (for other skills be as specific as possible)
Psychoeducation Around Youth's Diagnosis
Increase Parenting Skills
Increase Organizational Skills
Implement Routine and Structure
Access Community Resources
Increase Educational Advocacy Skills
Develop Natural Supports
None
Uncertain
Other
If Other was selected, please be as specific as possible.
HUB services (Therapeutic Mentoring & Family Support &Training) need to include the following in addition to this referral form:
*
Copy of most recent Comprehensive Assessment/Intake Note
Copy of most recent CANS Assessment
Copy of Safety Plan/Risk Assessment Form (if available)
Copy of Updated Treatment Plan, including a goal for TM/FS&T
Assessed Needs Checklist (See above)
Not Applicable
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