Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Date of ReferralSelect one or more services for referral Outpatient TherapyTherapeutic Mentoring (TM)Both, if applicableOther/Not SureTherapeutic Mentoring (TM) pairs a youth with an adult mentor to help the youth build and improve their social, communi cation, and life needs.– Typical frequency: Weekly sessions at home or in the community– Who can benefit: Youth who have moderate to severe behavioral health symptoms and who need support in the areas of problem-solving, social skills, communication, or conflict resolution. To receive TM, the youth also need to be receiving another behavioral health service (outpatient, IHT, IHBS, ICC or FIT).Enter youth/client informationFull Legal Name *Nickname/Chosen NameCurrent Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *Age *Grade in School--- Select Choice ---Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeCollegeOtherGender Identity (own words) *PronounsRace/EthnicityOtherPrimary LanguageOther Languages SpokenSchoolIs Youth on IEP/504 Plan?YesNoNextEnter parent/caregiver informationParent/Caregiver Name(s)Relationship to YouthPrimary LanguageOther Languages SpokenWho has the right to make medical and legal decisions for the Youth?AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmailPrimary PhoneOkay to leave a message?YesNoSecondary PhoneOkay to leave a message? YesNoNextEnter referral information (if referral source is not parent/caregiver)Referral Source NameAgencyPhoneEmailRelationship to Youth/ClientIs family aware of referral?YesNoNextEnter insurance and medical informationPrimary InsuranceSubscriber NamePrimary Care Physician (PCP)MassHealth/MMIS #Subscriber IDPCP PhoneSecondary InsuranceSubscriber NameSubscriber ID has referral Insurance Medical Conditions/AllergiesNextSpecify reason for referralProvide 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.)StrengthsAny of the following services in the last 30 daysHospitalCommunity-Based Acute TreatmentPartial Hospitalization programYouth Community Crisis StabilizationYouth Mobile Crisis InterventionOtherIf other, please explainInvolvement with other providersDCFDMHDYSSchoolOtherIf other, please explainNextFor Family Support and Training, and Therapeutic Mentoring:A Comprehensive Assessment and CANS completed for the youth – PLEASE ATTACHA Treatment Plan/Individualized Action Plan/Care Plan completed for the youth that includes a specific goal with objective outcome measures pertaining to the development of the parent/caregiver capacity to parent the youth in the home or community – PLEASE ATTACHFile Upload Drag & Drop Files, Choose Files to Upload Referrer's SignatureSignature * Clear Signature Submit