Date of Referral: *

September 2026
	S	M	T	W	T	F	S
36	30	31	1	2	3	4	5
37	6	7	8	9	10	11	12
38	13	14	15	16	17	18	19
39	20	21	22	23	24	25	26
40	27	28	29	30	1	2	3
41	4	5	6	7	8	9	10

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

Therapeutic Mentoring ⓘ Therapeutic Mentoring (TM) pairs a youth with an adult mentor to help the youth build and improve their social, communication, and life skills. To receive TM, the youth also needs to be receiving another behavioral health service (outpatient, IHT, IHBS, ICC, or FIT). Providers must send CANS, Comprehensive Assessment (if applicable), and the treatment plan with goals for the TM.	In-Home Behavioral Services ⓘ In-Home Behavioral Services (IHBS) is behaviorally based therapy for youth whose behaviors are significant enough to interfere with their functioning at home or in the community.
Family Support and Training ⓘ Family Support and Training (FS&T) is caregiver support and coaching. For caregivers to receive FS&T, the youth needs to be receiving another behavioral health service (outpatient, IHT, IHBS, or ICC). Providers must send CANS, Comprehensive Assessment (if applicable), and the treatment plan with goals for the FS&T.	Intensive Care Coordination ⓘ Intensive Care Coordination (ICC) is a care planning service for youth who have serious emotional and behavioral needs. ICC is intended for youth who need coordination across multiple services such as mental health, state agencies, special education, and other supports.
In-Home Therapy ⓘ In-Home Therapy (IHT) is intensive family therapy provided by a team of two behavioral health staff to help youth with social, emotional, or behavioral challenges.	Family-based Intensive Treatment ⓘ Family-based Intensive Treatment (FIT) combines intensive family therapy, care coordination, and caregiver support for youth with serious behavioral and emotional needs. FIT is for youth whose needs have required acute or urgent behavioral health services in the last 30 days, such as a crisis evaluation or an out-of-home placement.
Other

Location*

Holyoke	Lawrence
Worcester	New Bedford
Pittsfield	Boston
Fitchburg	Other

Enter Youth/Client Information

Full Legal Name:*

Nickname/Chosen Name:

Current Address:

Town:*

Date of Birth:*

Age:	Grade in School:

Gender Identity (own words):

Pronouns:

Race/Ethnicity:

Primary Language:*

Other Languages Spoken:

School:

Is Youth on IEP/504 Plan?

Yes No

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?*

Current Address:	Email Address:

Primary Phone:*	Okay to leave a message?* Yes No

Secondary Phone:	Okay to leave a message? Yes No

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

Referral Source Name:	Agency:

Phone Number:	Email Address:

Relationship to Youth/Client:	Is family aware of referral? Yes No

Enter insurance and medical information

Primary Insurance:*	MassHealth/MMIS/Policy #:*

Subscriber Name:	Subscriber ID:

Primary Care Physician (PCP):	PCP Phone:

Secondary Insurance:

Subscriber Name:	Subscriber ID:

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

Youth Mobile Crisis Intervention

Partial Hospitalization Program

Community-Based Acute Treatment

Youth Community Crisis Stabilization

Other

Involvement with other providers:

DCF

School

DMH