Thank you for your interest in the STAR Program at McLean Hospital. The STAR Program at McLean Hospital is a clinical outpatient program for adolescents and young adults ages 14-25 who are living in Massachusetts. Clients in the STAR program are experiencing changes in their thoughts, feelings, behaviors and are not functioning as well as they used to socially, at work, or at school. To determine eligibility for treatment at STAR, a comprehensive evaluation is conducted. This comprehensive evaluation is to determine if there is significant concern that the individual who is being referred is showing signs of risk for developing psychosis-spectrum illnesses and does not currently have a psychosis spectrum diagnosis.We are NOT a program designed to treat First Episode of Psychosis Program and are NOT appropriate for individuals who have a new or established psychosis diagnosis (such as schizophrenia, bipolar disorder or depression with psychosis, etc.), or who have been recently hospitalized for frank psychosis symptoms.
INSTRUCTIONS (please read carefully):
This referral form check list will ask for contact information for the person seeking treatment as well as a referring provider. Only one party needs to complete this form (either referring provider or the individual being referred/their family member, but NOT both). Below, you will enter information for both parties. Once you submit this initial form, you will be sent a link to fill out the full referral form. The link you are sent will be UNIQUE TO YOU and SHOULD NOT be forwarded. : If this referral is not for yourself, please ensure that the individual being referred is aware of referral and is in agreement with the referral being submitted on their behalf. Submission of this referral does not guarantee an appointment or services. The referral will be reviewed, and you may be contacted for more information as needed.
How did you access our referral form?
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Emailed to me
McLean website
Other
Emailed to me
McLean website
Other
If other, please specify:
In order to direct you to the appropriate referral form, please answer the following:
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I am a clinician in the community, private practice or other facility referring one of my clients/patients
I am the individual seeking services and I am 18 years old or older
I am referring the client/patient from a McLean unit/program
I am referring the client/patient from another Mass General Brigham facility/program
I am a parent/guardian/loved one of the individual seeking services
I am a clinician in the community, private practice or other facility referring one of my clients/patients
I am the individual seeking services and I am 18 years old or older
I am referring the client/patient from a McLean unit/program
I am referring the client/patient from another Mass General Brigham facility/program
I am a parent/guardian/loved one of the individual seeking services
First Name (Individual Seeking STAR Services):
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Last Name (Individual Seeking STAR Services):
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Email (Individual Seeking STAR Services):
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Initials (Individual Seeking STAR Services):
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This information will be included in the email sent to the person completing this form for identification purposes
Name (Referring Clinician):
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Email (Referring Clinician):
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What is your relationship to the client/patient?
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Primary Therapist or Prescriber
Inpatient, Residential, or Partial Case Manger/Clinician
Emergency Room Clinician
Other (specify)
Primary Therapist or Prescriber
Inpatient, Residential, or Partial Case Manger/Clinician
Emergency Room Clinician
Other (specify)
Did someone refer or recommend the STAR program to you?
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Yes
No
Name of individual who referred or recommended the STAR program to you:
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Relationship of individual who recommended the STAR program to the individual being referred:
* must provide value
Primary Therapist or Prescriber
Inpatient, Residential, or Partial Case Manger/Clinician
Emergency Room Clinician
Other (specify)
Primary Therapist or Prescriber
Inpatient, Residential, or Partial Case Manger/Clinician
Emergency Room Clinician
Other (specify)
Email address of individual:
* must provide value
Unit or Program at McLean:
* must provide value
(Optional) Anticipated discharge date:
Today M-D-Y
Referring McLean Clinician's Name:
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Referring McLean Clinician's Email:
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If patient is under 18 years old, name, phone number, and email address of parent/guardian
Medical record number (MRN) of individual seeking services
Date of birth of individual seeking STAR Services
Today M-D-Y
Please briefly describe primary reason for STAR referral and treatment goals:
Is the individual experiencing any of the following symptoms or risk factors?
Changes in thinking (odd ideas, grandiosity, suspiciousness, difficulty concentrating)
Changes in perception (auditory/visual/tactile/olfactory abnormalities)
Changes in speech (disorganized communication, tangential speech)
Dramatic reduction of overall functioning ((worsened performance at work or school, decline in hygiene, etc.)
First degree family member with a psychosis diagnosis
Unsure, would like to consult with STAR staff to better assess possible psychosis risk symptoms
Changes in thinking (odd ideas, grandiosity, suspiciousness, difficulty concentrating)
Changes in perception (auditory/visual/tactile/olfactory abnormalities)
Changes in speech (disorganized communication, tangential speech)
Dramatic reduction of overall functioning ((worsened performance at work or school, decline in hygiene, etc.)
First degree family member with a psychosis diagnosis
Unsure, would like to consult with STAR staff to better assess possible psychosis risk symptoms
Please give your best estimate of when these symptoms first started:
Is the individual taking any antipsychotic medication(s)?
Yes
No
What is/are the medication(s) and the current dose(s)?
Are you interested in any of the following to support the current referral:
Clinician to clinician curbside psychosis risk consultation: Curbside consultation via phone or zoom for you to talk with a STAR clinician to get feedback on if symptom presentation indicates psychosis risk profile, if your patient is appropriate for psychosis risk outpatient clinical services, and other questions related to assessing psychosis risk symptoms and referrals.
Brief psychosis risk symptoms assessment with the patient being referred: STAR clinician meeting with the patient you are referring to STAR to conduct a brief psychosis risk assessment to support referral decision making.
Brief family skills training: STAR clinician meeting with family members of the patient being referred to provide brief skills training on topics such as how to support their loved one in engaging in services, psychoeducation about early interventions for psychosis risk (e.g., different levels of care, risk and protective factors), how to talk about treatment, how family members can help their loved one, etc.
Clinician to clinician curbside psychosis risk consultation: Curbside consultation via phone or zoom for you to talk with a STAR clinician to get feedback on if symptom presentation indicates psychosis risk profile, if your patient is appropriate for psychosis risk outpatient clinical services, and other questions related to assessing psychosis risk symptoms and referrals.
Brief psychosis risk symptoms assessment with the patient being referred: STAR clinician meeting with the patient you are referring to STAR to conduct a brief psychosis risk assessment to support referral decision making.
Brief family skills training: STAR clinician meeting with family members of the patient being referred to provide brief skills training on topics such as how to support their loved one in engaging in services, psychoeducation about early interventions for psychosis risk (e.g., different levels of care, risk and protective factors), how to talk about treatment, how family members can help their loved one, etc.
Your Name:
* must provide value
Your Email:
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What is your relationship to the individual being referred?
* must provide value
Parent/guardian
Sibling
Other (specify)
Parent/guardian
Sibling
Other (specify)
Thank you for considering the McLean STAR Program and taking the time to complete this referral checklist.
Is the individual being referred between the ages of 14 and 25 years old?
* must provide value
Yes
No
Thank you for your interest in the STAR Program. Our program works with individuals who are between the ages of 14 and 25 years old; therefore, this individual is not eligible for the STAR program. Please refer to the Massachusetts psychosis Network for Early Treatment (MAPNET ) website for a list of additional treatment programs or contact the Massachusetts Psychosis Access & Triage Hub (M-PATH ) which is a free referral and consultation service available for anyone concerned about early psychosis.
Does the individual being referred live in Massachusetts?
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Yes
No
Thank you for your interest in the STAR Program. Due to licensing and insurance laws the STAR program only works with individuals who live in Massachusetts; therefore, this individual is not eligible for the STAR program. Please refer to the SAMHSA Treatment Locator for a list of treatment programs for serious mental illness outside of Massachusetts or Strong365 to find a national list of early psychosis programs.
Has the individual being referred been diagnosed with schizophrenia, bipolar disorder with psychosis/bipolar I, schizoaffective disorder, or "first episode psychosis/FEP"?
* must provide value
Yes
No
Thank you for your interest in the STAR Program. The STAR program is an early intervention program that works with individuals who are experiencing early symptoms that have not reached the level that qualifies for a specific psychosis diagnosis. We are not a program designed to treat First Episode of Psychosis Program and we are not appropriate for individuals who have a new or established psychosis diagnosis (such as schizophrenia, bipolar disorder or depression with psychosis, etc.); therefore, this individual is not eligible for the STAR program.
Please refer to the Massachusetts psychosis Network for Early Treatment (MAPNET ) website for a list of additional treatment programs or contact the Massachusetts psychosis Access & Triage Hub (M-PATH ) which is a free referral and consultation service available for anyone concerned about early psychosis.
Thank you for completing the STAR screening form. Once you hit 'submit' an email will be automatically sent to you with instructions and a unique link for you to use to complete STAR Referral Form. This second form must be completed to make a referral. Applications who only complete the first screening form above will not be reviewed. Once you complete this second form, the application will be reviewed, and a STAR staff member will follow up with further instruction/information. Please contact mclstarreferral@partners.org with questions.