In-Home Therapy Referral Form

Referral Source

Name of referral source:

Relationship to Youth:

Name of Agency:

Phone #:

Email:

Youth Information

First Name:

Last Name:

Name used by Youth:

Date of Birth:

Age:

Address:

Phone (if 18+):

Sex:

Gender:

Pronouns:

Race:

Ethnicity:

Primary language spoken:

Language to be used for services:

Involvement with other services (select all which apply):None/UnknownFamily-based Intensive Therapy (FIT)Intensive Care Coordination (ICC)Family Support & Training (FS&T)In-Home Behavioral Services (IHBS)Outpatient therapyTherapeutic Mentor (TM)Department of Children and Families (DCF)Department of Youth Services (DYS) (including for CRA)Department of Mental Health (DMH)Department of Developmental Services (DDS)Other

List other:

Involvement within the past 30 days with the following services (select all which apply):None/UnknownResidential programInpatient hospitalizationIntensive Outpatient (IOP)Community-Based Acute Treatment program (CBAT)Partial Hospitalization Program (PHP)Youth Mobile Crisis Intervention (YMCI) team

Is youth currently in an out-of-home placement with a plan to return to the home? If so, describe:

Insurance Plan:

Insurance ID:

Caregiver Information

Caregiver #1 name:

Relationship to Youth:

Address, if different than Youth:

Phone #:

Email:

Guardianship status:Legal and physicalLegal onlyPhysical onlyNoneUnknown

Primary language spoken:

Language to be used for services:

Add Second Caregiver

Caregiver #2 name:

Relationship to Youth:

Address, if different than Youth:

Phone #:

Email:

Guardianship status:Legal and physicalLegal onlyPhysical onlyNoneUnknown

Primary language spoken:

Language to be used for services:

If DCF holds legal guardianship, please provide the following information:

DCF Case Worker name:

Area Office:

Phone #:

Email:

Reason for Referral

Please provide a brief description of the event/s that led to this referral being made:

Please provide other information about the Youth and family relevant to this referral (eg, Youth’s diagnosis, other recent family stressors, and aims for treatment):

Please note any risk and safety factors experienced by the Youth and/or family (select all which apply):None known or reportedSuicidal ideation, planning, or actionsNon-suicidal self-injuryHomicidal/aggressive ideation, planning, or actionsRunning awaySubstance misuseWeapon/s in the homePhysical safety of family member/s at riskNeighborhood safetySignificant medical conditions/illnessOther

List other:

Requested Documentation

Please note:

If the Youth is involved with Intensive Care Coordination, the ICC must submit the most recent safety plan, Individual Care Plan outlining goals for IHT, and minutes or agenda from the last Care Planning Team.
If DCF or an alternative caregiver is the legal guardian of the Youth, the case worker must submit the guardianship mittimus outlining guardianship and custody.
Other providers involved with the Youth and family are encouraged but not required to submit recent safety plans, treatment plans, assessments, or other documentation relevant to referral and services.

Upload documentation

Or send separately

Email to MAhomebasedservices@c4p.org
Fax documentation to 617-499-7684

For questions about In-Home Therapy or making a referral, please email MAhomebasedservices@c4p.org or call 1-855-801-4622.