New CBHI

Children's Behavioral Health Initiative (CBHI): Standard Referral Form (2 of 3)
Date of Referral

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

Other
Enter youth/client information
Full Legal Name
NicknameChosen Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Grade in School
Gender Identity own words
Pronouns
RaceEthnicity
Other
Primary Language
Other Languages Spoken
School
Enter parent/caregiver information
Parent/Caregiver Names
Relationship to Youth
Primary Language
Other Languages Spoken
Who has the right to make medical and legal decisions for the Youth
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
Enter referral information (if referral source is not parent/caregiver)
Referral Source Name
Agency
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Relationship to Youth/Client
Enter insurance and medical information
Primary Insurance
Mass/Health/MMIS #
Subscriber Name
Subscriber ID
Primary Care Physician PCP
PCP Phone
Format: (000) 000-0000.
Secondary Insurance
Subscriber Name
Subscriber ID
Medical Conditions/Allergies
Specify reason for referral
Provide a brief description of your goals safety concerns diagnosis andor other needs in making referral
Risk factors eg DV SI HI substance use trauma etc
Strengths
Any of the following services in the last 30 days:
Other:
Service Request
Service Request
- Typical frequency: weekly sessions at home or in the community

- Who can benefitL Youth who have moderate to severe behavioral health sysmptoms 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).
- Typical frequency: 1-2 sessions per week that occur at home or in the community

- Who can benefit: Caregivers who want to become more effective advocates for their child through understanding how to navigate systems and access community support. For caregivers to receive FS&T, the youth needs to be receiving another behavioral health service (outpatient, IHT, IHBS or ICC).
- Typical frequency: 1-3 sessions per week that occur at home or in the community.

- Who can benefit: Families of youth with moderate to severe behavioral health symptoms who want help to resolve conflicts, learn new ways to talk to and understand each other, create new helpful routines, and find community resources
- Typical frequency: 1-3 sessions per week that occur at home or in the community

- Who can benefit: Youth whose behaviors are significant enough to interefere with their functioning at home or in the community
- Typical frequency: Minimally 1 contact per week at home, in the community, or by phone

- Who can benefit: Youth with serious behavioral health symptoms, including youth with co-occuring mental health and autism spectrum disorder, who need coordination across multiple services (mental health, state agency, special education, etc.). The care coordinatior facilitates a team-based process including professionals and natural supports to create one plan.
- Typical frequency: 3-5 sessions per week that occur at home or in the community

- Who can benefit: Youth experiencing significant behavioral health sysmptoms, including co-occuring health and autism spectrum disorder, whose needs have required acute/urgent behavioral health services in the last 30 days such as a crisis evaluation or an out-of-home placement. The focus of this service is to stabilize the youth's behavioral needs, strengthen the family and community supports, and transition to outpatient therapy or IHT in 4-6 months.
Other
For Family Support and Training, and Therapeutic Mentoring:
File Upload

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Type a question
Should be Empty:

Enter youth/client information

Enter parent/caregiver information

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

Enter insurance and medical information

Specify reason for referral

Service Request

Other