HBT Referral

THIS IS A REFERRAL FOR:
Intensive Care CoordinationIn Home TherapyTherapeutic MentoringFS+T Only
REFERRAL FORM
Date:

MonthDayYear
Date
Referral Source:
Referral Source Phone
Reason for Referral:
Did Parent Give Verbal and/or Signed Consent for Referral?

YesNo
**Referrer asked to forward: Release from parent/guardian, any assessments, safety plans, discharge from LOC, IEP, etc.
GENERAL/CHILD INFORMATION:
Name:
DOB:
SSN:
Primary/Commercial Insurance:
MassHealth Number:
MBHP:
NHP:
BMCH:
Fallon:
Gender:
Diagnosis (Not PDD/Autism):
Who gave diagnosis? When?
School:
Grade:
IEP:

yesno
PARENT/GUARDIAN CONTACT:
Name(s)
Address
Phone (Home):
Phone (Cell):
Please enter a valid phone number.
Custody Issues: (ask for court paperwork):
Best time to call:
Primary Language:
Will an interpreter be needed?

yesno
Referral/Open Providers and/or state agencies involved:
SAFETY: (please explain all yes answers)
Are there any weapons in the home?

YesNoExplain:
Are there any immediate safety concerns?

YesNoExplain:
Who else is living in the home?
Are any pets in the home?

YesNoWhat Kind:
How are the pets around other people?
Information about entrance to building and parking:
Should be Empty:

REFERRAL FORM