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
*
In-Home Therapy
Intensive Care Coordination & Family Partner Services
Therapeutic Mentoring
Family Support & Training (Family Partner Only)
Family-Based Intensive Treatment
Not Sure
Please note that Therapeutic Mentoring and Family Support & Training (Family Partner Only) require a clinical hub to complete the refferal.
Qualified hubs include an Intensive Care Coordinator, In-Home Therapist, or Outpatient Therapist.
Please Select Your Town.
Please Select
Arlingtion
Belmont
Canton
Dedham
Dover
Foxborough
Lexington
Medfield
Millis
Needham
Newton
Norfolk
Norwood
Plainville
Sharon
Walpole
Waltham
Watertown
Wellesley
Weston
Westwood
Wrentham
If your location is not listed, it's outside our catchment area.
Please Select Your Town.
Please Select
Canton
Dedham
Dover
Foxborough
Medfield
Millis
Needham
Newton
Norfolk
Norwood
Plainville
Sharon
Walpole
Wellesley
Weston
Westwood
Wrentham
If your location is not listed, it's outside our catchment area.
Youth Information
Youth's Full Legal Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth's Date of Birth
*
-
Month
-
Day
Year
Date
Please Provide the Following Information
*
Youth's Diagnosis
Please include all diagnoses
Caregiver 1
Please note that there is no distinction between Caregivers 1 & 2.
Full Legal Name
*
First Name
Last Name
Relationship to Youth
*
Primary Language
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Ok to Leave a Message?
*
Yes
No
Email Address
*
Is this Caregiver the Referrer?
*
Yes
No
Who Has the Right to Make Medical Decisions for Youth?
*
Caregiver 2
Optional
Full Legal Name
First Name
Last Name
Relationship to Youth
Primary Language
Email Address
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Ok to leave a message?
Yes
No
Enter Referral Information
Name
*
First Name
Last Name
Agency
*
Relationship to Youth
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Is Youth's Family Aware of Referral?
*
Yes
No
Additional Referral Information
Reason for Referral
*
Why does youth require Riverside's support?
Safety Concerns
*
Has Youth Received Any of the Following Services Within 45 Days? Please Select all that Apply.
*
Hospital
Youth Community Crisis Stabilization
Community-Based Acute Treatment
Mobile Crisis Intervention
Partial Hospitalization Program
None
Other
Insurance & Medical Information
Required
Primary Insurance
*
Subscriber Name
*
First Name
Last Name
Subscriber ID
*
Secondary Insurance
Subscriber Name
Subscriber ID
If Interested in Therapeutic Mentoring or Family Support & Training, Please Submit the Required Files
Comprehensive Assessment and CANS Completed for Youth
*
Browse Files
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of
Completed Treatment Plan/Care Plan with Specific Goals and Measurable Outcomes Pertaining to the Development of Caregiver Capacity to Successfully Raise Youth
*
Browse Files
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Cancel
of
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.
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