communityempowermentservices.com

Referral Form
Referrer Information
Referring Organization / Practice Name
Referrer Name
School CounselorSocial WorkerTherapistPediatrician / Medical ProviderCase ManagerHospital / Discharge PlannerOther (please specify)
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EmailPhone
YesNo
Client Information
Client Name

First NameLast Name
Client Date of Birth

MonthDayYear
Date
Client Age Range
Client Gender
Reason for Referral
Please provide a brief description of the concerns prompting this referral
Insurance Provider, if known
Service Preferences
Individual TherapyFamily TherapyCouples TherapyGroup TherapyUnsure / Clinical Recommendation
Taunton officeNorth Andover officeGeorgetown officeTelehealthUnsureNo preference
Yes, consent has been obtained.
How did you hear about us?
Non-Emergency Use Only

This referral form is intended for non-emergency outpatient mental health services only. Community Empowerment Services does not provide crisis intervention or emergency services through this form.

If the client is experiencing an emergency, is at imminent risk of harm to themselves or others, or requires immediate assistance, do not submit this form. Please contact 911, go to the nearest emergency department, or call the 988 Suicide & Crisis Lifeline for immediate support.

Submission of this referral does not guarantee immediate services. All referrals are reviewed by our administrative and clinical team, and follow-up will occur as availability allows.
Should be Empty:

Referral Form

Referrer Information

Client Information

Service Preferences