HOW TO SUBMIT A REFERRAL• Please complete all fields on this form. This is a secure, encrypted submission. Once this form is submitted you will receive an email receipt to the email address you provided for yourself. If you do not receive this receipt, please contact the Patient Service Coordinator at (617) 643-1175.
• It is highly encouraged to submit the referral form online.
• Alternatively, you may contact the Patient Service Coordinator to complete this referral over the phone or if you have any questions about the referral process.
NOTICE: PATIENT MUST BE REGISTERED with PATIENT SERVICE CENTER BY CALLING (866) 211-6588 PRIOR TO SUBMITTING REFERRAL. Please be prepared with name, date of birth, address, insurance plan and member number for patient being referred. You will be provided a medical record number (MRN#) to enter on this form.
IMPORTANT
If 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. Specific program capacity may be limited. The referral will be reviewed and you may be contacted for more information as needed. If based on this screening the patient is found to be potentially eligible for our services, patients will next need to attend an initial evaluation with a provider. After that evaluation, the provider and treatment team will determine whether the patient will be offered ongoing care in one of our programs.
We may be unable to provide services to individuals who have certain disorders or medical conditions for which our program is not well-suited to treat.
It is recommended to check with your health insurance provider to see if you are covered for services with Massachusetts General Hospital and learn the specifics of your coverage. Additional information can be found at: https://www.massgeneral.org/notices/billing/insurance
Date of Referral
* must provide value
Today M-D-Y
What is your relationship to the patient being referred?
* must provide value
Patient (referring myself)
Parent or guardian of a patient who is under the age of 18 years
Parent or guardian of a patient who is 18 years or older
Current treater (therapist, psychiatrist, prescriber, social worker, primary care provider) of a patient
Current outpatient treater (therapist, psychiatrist, prescriber, social worker, primary care provider) of a patient
Current treater at inpatient hospital, emergency room, or partial hospitalization (therapist, psychiatrist, prescriber, social worker) of a patient
Other
What is your relationship to the patient being referred?
* must provide value
What is your contact information (email, phone)?
* must provide value
Does the patient have a court-appointed legal guardian?
Yes
No
Patient Information:
* must provide value
first name last name
Patient preferred name (if applicable)
Patient date of birth
* must provide value
Today M-D-Y
Patient age
* must provide value
View equation Does the patient or the patient's legal guardian consent to this referral?
* must provide value
Yes
No
Do the patient's parents or legal guardians consent to this referral?
* must provide value
Yes
No
Thank you for your interest in our program. We are not able to accept referrals if the patient is 18 years or older and does not consent to evaluation in our program.
Patient sex assigned at birth
* must provide value
Male
Female
Intersex
Patient gender
* must provide value
Male
Female
Non-binary
Transgender Male
Transgender Female
Genderqueer
Other
Choose not to disclose
Patient preferred pronouns
* must provide value
He/him/his
She/her/hers
They/them/theirs
Ze/Hir/Hirs
Other
No pronoun preference
Please specify patient preferred pronouns
* must provide value
What best describes ______ 's racial identity?
* must provide value
American Indian or Alaskan Native
Asian, Asian American, or Pacific Islander
Black or African American
Hispanic or Latino/a/x
Middle Eastern or North African
White
Multiracial or biracial
Other
A race/ethnicity not listed here
Prefer not to say
Please specify ______ 's racial identity:
* must provide value
Patient's MGH Medical Record Number (if pt does not have an MGH MRN, please call patient registration at 866-211-6588)
* must provide value
What type of insurance does ______ have?
No insurance
Commericial (private) insurance (i.e. Blue Cross, Harvard Pilgram, Aetna)
Mass Health or Medicaid
Other
Patient's Address:
* must provide value
What is the patient's primary spoken language?
* must provide value
English
Spanish
Portuguese
Chinese (Mandarin)
Chinese (Cantonese)
French
Arabic
Other
If other, what is the patient's primary spoken language?
* must provide value
Patient's phone:
* must provide value
What is an alternative way to reach ______ ?
* must provide value
Do you give us permission to contact you by email?
* must provide value
Yes
No
Include name and contact information for someone who would know how to reach you in case of emergency (name, email, cell phone number):
* must provide value
Parent/guardian information:
First parent/guardian name:
First parent/guardian address:
First parent/guardian phone number:
First parent/guardian email address:
Address
* must provide value
Phone
* must provide value
Email
* must provide value
Do we have permission to leave a message or send an email?
Yes
No
What is the first parent/guardian's primary spoken language?
* must provide value
English
Spanish
Portuguese
Chinese (Mandarin)
Chinese (Cantonese)
French
Arabic
Other
If other, what is the first parent/guardian's primary spoken language?
* must provide value
Is there a second parent/guardian?
* must provide value
Yes
No
If yes, our office will be contacting both parents/guardians, so please provide names and contact information.Second parent/guardian name: Address: Email: Phone:
If yes, our office will be contacting both parents/guardians, so please provide names and contact information. Second parent/guardian name:
* must provide value
Second parent/guardian address:
* must provide value
Second parent/guardian phone:
* must provide value
Second parent/guardian email:
* must provide value
Are parents/guardians:
* must provide value
married
separated
divorced
not together
other
Are both parents/guardians in agreement with this referral?
* must provide value
Yes
No
Thank you for your interest in our program. We are not able to accept referrals if the patient's parents/guardians are not in agreement with referral to our program.
Who has legal custody of ______ ?
* must provide value
If other, who has legal custody of ______ ?
* must provide value
Who has physical custody of ______ (i.e. with whom does ______ live)?
* must provide value
If other, who has physical custody of ______ ?
* must provide value
IF YOU ARE A PROVIDER COMPLETING REFERRAL:
Name:
Email:
Phone number:
Name of practice/agency:
Role (e.g. therapist, psychiatrist, prescriber, social worker, etc.):
Did ______ agree (or their parents if under 18) to be contacted by MGH for this referral?
If yes, indicate which means patient or patient's parents/guardians are agreeable to be contacted (check all that apply):
IF YOU ARE A PROVIDER COMPLETING REFERRAL:
* must provide value
Phone number:
* must provide value
Email:
* must provide value
Name of practice/agency
* must provide value
Role (e.g. therapist, psychiatrist, prescriber, social worker, etc.)
* must provide value
Did patient or parents/guardians agree to be contacted about this referral?
* must provide value
Yes
No
How did the patient or patient's parents/guardians are agree to be contacted (check all that apply) about this referral?
* must provide value
How did you learn of our services?
* must provide value
If so, please provide the name of the provider/agency:
* must provide value
If so, please provide the name of the hospital/emergency/crisis service:
* must provide value
If so, please let us know how you learned about our program:
* must provide value
Who is ______ 's primary care provider? ______ does not have a PCP, you can call (800) 711-4644 to obtain an MGH PCP.
Who is ______ 's primary care provider?______ does not have a PCP, you can call (800) 711-4644 to obtain an MGH PCP.
practice name and address
practice name and address
practice name and address
If you are referring yourself and you are 18 years or older, please list any family members that you are willing to have contacted to provide additional information to help with referral (about current difficulties, history, and how treatment may be helpful?
Name Relationship Contact information (email/phone number) Do you give us permission to contact this family member?
I agree to have this ______ contacted to provide more information:
Yes
No
I agree to have this ______ contacted to provide more information:
Yes
No
I agree to have this ______ contacted to provide more information:
Yes
No
I agree to have this ______ contacted to provide more information:
Yes
No
I agree to have this ______ contacted to provide more information:
Yes
No
Is there a specific program you are interested in?
* must provide value
RE-SET
FEPP
ROCC
I'm not sure
Please list the names of any other psychosis-risk or early intervention/first episode psychosis programs where you have also placed a referral or plan to do so in the immediate future (i.e. CEDAR, STARR):
Please list the names of any other psychosis-risk or early intervention/first episode psychosis programs where you have also placed a referral or plan to do so in the immediate future (i.e. CEDAR, STARR):
Please list the names of any other psychosis-risk or early intervention/first episode psychosis programs where you have also placed a referral or plan to do so in the immediate future (i.e. CEDAR, STARR):
Please list the names of any other psychosis-risk or early intervention/first episode psychosis programs where you have also placed a referral or plan to do so in the immediate future (i.e. CEDAR, STARR):
Please list the names of any other psychosis-risk or early intervention/first episode psychosis programs where you have also placed a referral or plan to do so in the immediate future (i.e. CEDAR, STARR):
Please list the names of any other psychosis-risk or early intervention/first episode psychosis programs where you have also placed a referral or plan to do so in the immediate future (i.e. CEDAR, STARR):
Please state the outcome of any of these referrals (pending, evaluation scheduled, not found eligible, etc).
Please state the outcome of any of these referrals (pending, evaluation scheduled, not found eligible, etc).
Please state the outcome of any of these referrals (pending, evaluation scheduled, not found eligible, etc).
Please state the outcome of any of these referrals (pending, evaluation scheduled, not found eligible, etc).
Please state the outcome of any of these referrals (pending, evaluation scheduled, not found eligible, etc).
Please state the outcome of any of these referrals (pending, evaluation scheduled, not found eligible, etc).
Please list the names of any other psychosis-risk or early intervention/first episode psychosis programs where you have also placed a referral or plan to do so in the immediate future: Please list the outcome of each of these referrals (pending, evaluation scheduled, not found eligible, etc).
PSYCHIATRIC INFORMATION
* must provide value
What psychiatric diagnoses has ______ ever received?
Diagnosis (i.e. depression, schizophrenia, ADHD) Estimated date of diagnosis Who made this diagnosis?
(i.e. depression, schizophrenia, ADHD)
Estimated date diagnosis given:
Provider/facility who made diagnosis:
(i.e. depression, schizophrenia, ADHD)
Estimated date diagnosis given:
Provider/facility who made diagnosis:
Estimated date diagnosis given:
Provider/facility who made diagnosis:
Estimated date diagnosis given:
Provider/facility who made diagnosis:
Estimated date diagnosis given:
Provider/facility who made diagnosis:
Please provide information for any of your current providers (as applicable) :
Name Contact info If you are the patient or the parent referring a patient under 18, do you grant us permission to contact this provider? Is a referral to this service/provider pending? Prescriber/psychiatrist: Therapist: Family therapist: School counselor: Group therapist: Department of Mental Health (DMH) Services primary provider: DMH Adult Community Clinical Services (ACCS):
Case manager: In-home therapist: Applied Behavior Analysis (ABA) therapist: Therapeutic mentor: Department of Developmental Services (DDS) primary provider: Department of Youth Services (DYS) primary provider: Department of Children and Families (DCF) team:
Current psychiatric treaters (if applicable):Psychiatrist/nurse practitioner/prescriber name:
Psychiatrist/nurse practitioner/prescriber contact information:
Yes
No
Therapist/psychologist name:
Therapist/psychologist contact information:
Yes
No
Family therapist contact information:
Yes
No
school counselor contact information:
Yes
No
group therapist contact information:
Yes
No
DMH team contact information:
Yes
No
ACCS team contact information:
Yes
No
case manager contact information:
Yes
No
in home team contact information:
Yes
No
ABA therapist contact information:
Yes
No
Therapeutic mentor contact information:
Yes
No
DDS team contact information:
Yes
No
DYS team contact information:
Yes
No
DCF team contact information:
Yes
No
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