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Location
Home
Services
Behavioral Health
Outpatient Services
Children's Behavioral Health Initiative (CBHI)
In-Home Therapy (IHT)
Structured Outpatient Addiction
Therapeutic Mentoring
Family Support and Training (FST)
Mobile Crisis Intervention
Addiction And Substance Program
Medication-Assisted Treatment (MAT)
Vivitrol Treatment
Intensive Outpatient Program
Drug And Alcohol Individual Therapy
Problem Gambling Therapy
Driver Alcohol Education
Recovery Coaching
The Second Offender Program
Resources
Psychiatric & Behavioral Treatment Links
Careers
Forms
Insurance
United Health Care
Optum
Allways
MyCare Family
Harvard Pilgrim
About
Contact
Request Services
Resources
Home | Resources | Forms
All referrals for medication Services must have a medication list attached
To Refer Other Services to Family Continuity---Program Type
Medication Management
Family Stabilization Treatment (FST)
Outpatient Service
In Home Therapy (IHT)
Therapeutic Mentor (TM)
Addiction & Substance Use
Recovery Coaching
Intensive Outpatient Program (IOP)
Drug & Alcohol Education
Partial Hospitalization Program (PHP)/SOAP
Personal Info
Referred by
Self
Other If Other
Referral Source Name:
Referral Source Phone Number:
What is the Relationship?
Gender
Male
Female
Transgender
Person’s Full Name (First MI Last):
Phone Number:
Ext:
Has the person received services here before?
Yes
No
State Agency Involvement:
DCF
DDS
DMH
DYS
N/A
Reason(s) for requesting treatment:
D.O.B:
SSN
Best Phone # to Contact:
Ok to leave message
Person’s Address :
Person is Homeless
Legal Guardian:
Legal Guardian Telephone #:
State Agency Involvement:
Yes
No
Don’t Know
Name of Referring CSA, Provider or Family Member:
Special Communication Needs:
TDD/TTY Device
Sign Language Interpreter
Assistive Listening Device(s)
Language Interpreter Services Needed
Other
Special Accommodations:
None
Reported:
Other Spoken Language :
Other :
Ethnicity:
African American
American Indian/Alaskan
Asian
Hispanic
Multiracial
Native Hawaiian/Pacific Islander
Caucasian
Unknown
Axis I /Mental Health Diagnosis:
Day/Times Person/Family is available to be seen:
a.m
p.m
Day of week:
M
W
Th
F
Sat
Sun
Insurance Information
Has insurance
Self Pay
No insurance
Primary Insurance Company Name:
Policy Number/MMIS:
Policy Holder Name:
Policy Holder SSN:
Secondary Insurance:
Non-Insurance Options (check one):
Reduced Rate (Complete Application with client and turn into the Clinic Director for approval)
Hardship (Complete Application with client and turn into the Clinic Director for approval)
Self-Pay (payment in full)
Quality Management Information (to be completed by the Clinician)
MIS #:
Clinician assigned to person/family:
Date clinician called:
Date first appointment offered:
Date of first appointment:
Submit
