Accessing Riverside's Services

Accessing Riverside's Services

Thank you for your interest in Riverside Community Care's services. Please fill out the following form so we can best support you.
Please Select One or More Services for Referral
Please note: Therapeutic Mentoring and Family Support & Training (Family Partner) require the youth to be engaged with a clinical hub provider at the time of referral.

Qualified clinical hubs include Intensive Care Coordination (ICC), In-Home Therapy (IHT), or Outpatient Therapy.

Required clinical hub documentation must also be uploaded below with the referral.
Please Select Your Town.
If your location is not listed, it's outside our service area.
Please Select Your Town.
If your location is not listed, it's outside our service area.
Please Submit the Required Documents Below for Therapeutic Mentoring or Family Support & Training
Comprehensive Assessment and CANS Completed for Youth

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Completed Treatment Plan/Care Plan with Specific Goals and Measurable Outcomes Related to the Requested Service

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Youth Information
Youth's Full Legal Name

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Youth's Gender Identity:
Youth's Race/Ethnicity:
Youth Primary Language:
Please enter the youth's primary language:
Is an interpreter desired for the youth?
What School does the youth attend?
Please enter the youth’s current school. If you are unsure, enter “Unsure.”
What grade is the youth in?
Please enter the youth’s current grade. If you are unsure, enter “Unsure.”
Does the youth have an IEP or 504 Education Plan?
Youth's Diagnosis
Please include all diagnoses. If there's no known diagnosis, enter "none".
Is the youth currently taking any prescription medications?
Please list the youth's current prescription medications, if known
Do not include vitamins, supplements, or over-the-counter medications.
Does the youth have any known allergies?
Please list the youth’s allergies, if known
Caregiver 1

Please note that there is no distinction between Caregivers 1 & 2.
Full Legal Name

First NameLast Name
Relationship to Youth
Caregiver 1 Primary Language:
Please enter caregiver 1's primary language:
Is an interpreter desired for caregiver 1?
Other Languages Spoken, if any
Leave blank/empty if none
Caregiver 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ok to Leave a Message?
Caregiver 1 Email Address
Is this parent/guardian completing this referral form?
Please list all individuals who have legal authority to make medical decisions for the youth.
Please include all parents, guardians, or other individuals with medical decision-making authority.
Caregiver 2

Optional
Full Legal Name

First NameLast Name
Relationship to Youth
Caregiver 2 Primary Language:
Please enter caregiver 2's primary language:
Is an interpreter desired for caregiver 2?
Other languages spoken, if any
Leave blank/empty if none
Caregiver 2 Email Address
Caregiver 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Enter Referral Source Information
Name

First NameLast Name
Agency
Relationship to Youth
Referral Source Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source Email Address
Is Caregiver 1 Aware of the Referral?
Additional Referral Information
Reason for Referral
Please briefly describe the youth’s current needs, presenting concerns, and what support is being requested.
Safety Concerns
Please describe any current or recent safety concerns.
Has Youth Received Any of the Following Services Within 45 Days? Please Select all that Apply.

Other
Insurance Information

Required
Primary Insurance
Subscriber Name

First NameLast Name
Subscriber ID
Secondary Insurance
Subscriber Name
Subscriber ID
Please Note That Responses To This Form Are Not Monitored 24/7.

This form is checked periodically during business hours and is not intended for urgent or crisis situations. If you require immediate help, call or text the Massachusetts Behavioral Health Help Line at 833-773-2445 or the Suicide & Crisis Lifeline at 988.
Should be Empty:

Accessing Riverside's Services

Please note: Therapeutic Mentoring and Family Support & Training (Family Partner) require the youth to be engaged with a clinical hub provider at the time of referral.

Qualified clinical hubs include Intensive Care Coordination (ICC), In-Home Therapy (IHT), or Outpatient Therapy.

Required clinical hub documentation must also be uploaded below with the referral.

Please Submit the Required Documents Below for Therapeutic Mentoring or Family Support & Training

Youth Information

Caregiver 1

Caregiver 2

Enter Referral Source Information

Additional Referral Information

Insurance Information

Please Note That Responses To This Form Are Not Monitored 24/7.