Behavioral Health Outpatient Services Intake Form

Member Date of Birth*

Parent/Guardian Date of Birth

Parent/Guardian Relation*

Parent/Guardian Email*

Parent/Guardian Phone*

Emergency Contact Phone

Relationship to Member

Secondary Insurance

Member Masshealth ID/Subscriber ID#

Please provide number beginning with “N” if the member has Tufts.

Reason for Referral*

Please include a DETAILED description and include youth’s behaviors, requested treatment goals for the youth and family as well as any safety concerns. If there is DCF involvement please include that also.

Past/Current Services*

Please list any behavioral health services the member has had, even if it includes CSR, and indicate if they are “current” or “past”.

Please add diagnosis*

Please add details

Type of Medication(s)

School Information

School Name

School Phone Number

Member Grade Level

Referral Source Information

Please include your name and contact information. Please fax supporting documents to 617-749-2430.

Referral Source Full Name*

Referral Source Agency and/or Relationship to Member

Referral Source Email*

Referral Source Phone*

Referral Source Fax

How did you hear about us?

Please list and past or current behavioral health services the member has even if it includes CSR.

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Behavioral Health Referral Intake Form

School Information

Referral Source Information