Referral Form

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Children's Behavioral Health

Hispanic Specialty CSA Statewide

For inquiries about (Intensive Care Coordination, Family Support, and Training and Family-Based Intensive Treatment) services statewide that are not listed on the locations below, please contact 413-846-0445.

CBHI Services

(In-Home Therapy, In-Home Behavioral and Therapeutic Mentor)

For inquiries about services or support with completing a CBHI referral,

please contact one of the following offices below.

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Date of Referral: *

Month

Day

Year

Select one or more services for referral (see descriptions below)

Therapeutic Mentoring

Family Support and Training

In-Home Therapy

In-Home Behavioral Services

Intensive Care Coordination

Family-based Intensive Treatment

Other/Not Sure

Enter youth/client information

Full Legal Name:*

Address*

Birthday*

Month

Day

Year

Age

Grade in School

Gender Identity (own words):

Pronouns

Race/Ethnicity:

Primary Language:

Other Languages Spoken

School

Is Youth on IEP/504 Plan?

Yes

Enter parent/caregiver information

Parent/Caregiver Name(s):

Relationship to Youth

Primary Language

Other Languages Spoken

Who has the right to make medical and legal decisions for the Youth?

Address

Phone

Okay to leave a message?

Yes

Secondary Phone

Enter referral information (if referral source is not parent/caregiver)

Referral Source Name:

Agency

Phone

Relationship to Youth/Client:

Is family aware of referral?

Yes

Enter insurance and medical information

Primary Insurance:

MassHealth/MMIS #:

Subscriber Name:

Subscriber ID:

Primary Care Physician (PCP)

PCP Phone:

Secondary Insurance:

Subscriber Name:

Medical Conditions/Allergies:

Specify reason for referral

Provide a brief description of your goals, safety concerns, diagnosis, and/or other needs in making referral:

Risk factors (e.g., DV, S/I, H/I, substance use, trauma, etc.):

Strengths:

Any of the following services in the last 30 days:

Hospital

Partial Hospitalization Program

Youth Community Crisis Stabilization

Youth Mobile Crisis Intervention

Community-Based Acute Treatment

Other:

Involvement with other providers:

Other:

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