The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

gsxL5or8hbVnWtRE2JFX56XmdXErkr7xVZewSGRY8Z4nwdwn9RHYjF4TBoD7xnDY5w7m7cbJ2MjLywLq6DGMKDcWbXS8wQYfqFQT5nCXKWi4BHyZq

Resource-finding Online Referral Form

Welcome to Mass General Brigham resource-finding. Your request will be sent to the resource team for processing. We will provide resources as close to your address as possible.

If you are on Patient Gateway, resources will be sent by Patient Gateway message. If you are not on Patient Gateway, you will be notified via phone.

For help with substance use, please contact the Mass Substance use hotline directly at 800-327-5050 instead of filling out this form.

For Outpatient Therapy, Outpatient psychiatry, Support group resources, please fill out the information below to start your request.

First name:

* must provide value

Last name:

* must provide value

Date of Birth:

* must provide value

M-D-Y

Street:

* must provide value

Town/City:

* must provide value

State:

* must provide value

Zipcode:

* must provide value

Phone number:

* must provide value

Can a voicemail be left that will contain resources ?

* must provide value

Yes

reset

Primary Health Insurance:

* must provide value

Aetna

Cigna

Beacon

Blue Cross Blue Shield

Harvard Pilgrim Healthcare

Medicaid/MassHealth - Mass General Brigham Health Plan ACO

Mass General Brigham Health Plan HMO/PPO

Medicare

Optum

Tufts

UniCare

United Healthcare

reset

Insurance ID Number (ex: Health Plan ID # 0000000000)

* must provide value

1. Is MassHealth/Medicaid your primary insurance?

* must provide value

Yes

reset

3. Can we provide all necessary information to behavioral health provider/clinic/office in order to schedule a behavioral health appointment on your behalf?

* must provide value

Yes

reset

4. If we have your consent to schedule a behavioral health appointment for you on your behalf, please specify what days and times will generally work for you in order to attend appointments:

* must provide value

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Saturday AM

Saturday PM

Sunday AM

Sunday PM

5. Would you prefer a phone call or patient gateway message with the appointment information?

* must provide value

Phone Call

Patient Gateway

reset

Insurance Name (Please include full name of insurance and any other specifics such as policy holder):

* must provide value

Expand

Secondary Health Insurance (If applicable):

Primary Care Provider Name:

* must provide value

Primary Care Practice Name:

* must provide value

Primary Care Phone Number:

* must provide value

Check all that apply

* must provide value

Outpatient Therapy (Talk Therapy/Counseling)

Outpatient Psychiatry (Medication)

Support Group

Please specify any preferences for providers (for instance: lesbian, Black or African American, Spanish speaking or an older adult.):

Please specify any preferences for providers (for instance: lesbian, Black or African American, Spanish speaking or an older adult):

* must provide value

Please specify support group type:

* must provide value

Check all that apply

* must provide value

Anxiety

Depression

Grief/bereavement

Trauma/PTSD

Anger Management

Gender Identity

ADHD/ADD

Eating Disorders

Other

If other, please specify:

* must provide value

Check all that apply

* must provide value

I cannot find providers that will take my insurance

I cannot find providers that speak my primary language

Providers haven't called me back

Other

If other, please specify:

* must provide value

If you have a Patient Gateway account, resources will be sent via Patient Gateway, otherwise phone outreach will be made.

Office Use Only

Intake Contact:

Assigned Resource Specialist:

Date Received:

M-D-Y

RSO Name

Resources Provided:

Expand

Date Resources Provided:

M-D-Y

Date Of Follow Up:

M-D-Y

Race:

White

Black or African American

American Indian or Alaska native

Asian

Native Hawaiian or other Pacific Islander

Other

Declined /unavailable

reset

Ethnicity:

Hispanic

Not Hispanic

Declined/Unavailable

reset

Language:

English

Spanish

Portuguese

Arabic

Russian

Traditional Chinese

Haitian Creole

Other

Unknown/declined

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.