Please fill out this form to the best of your ability. If you are having any difficulties, please feel free to reach out to us at cedarclinic@brooklinecenter.org or 857-707-3478.

Please note that all fields with an * are required

Referral Information
*What is your relationship to the youth or young adult being referred?*
*Is the youth aware you are making this referral?*	Yes No
Youth/Young Adult’s Information
*What is person’s legal name* (First and Last)
What name does the person prefer? (First and Last)
*Date of Birth*
*What is the person’s sex assigned at birth?* (female, male, intersex)
*What is the person’s gender identity?* (Woman, man, transmasculine, transfeminine, etc.)
*What are the person’s pronouns* (She/Her, He/Him, They/Them, etc.)
*What best describes the person’s racial identity?*	American Indian or Alaskan Native Asian, Asian American, or Pacific Islander Black or African American Latino/a/x Middle Eastern or North African White Multi-Racial or biracial Other Prefer not to say
Please fill in if the person identifies as another racial identity not listed.
*What best describes the person’s sexual orientation?*	Heterosexual Gay Lesbian Bisexual Pansexual Queer Other Don’t Know Prefer not to say
Please fill in if the person identifies as another sexual orientation not listed.
What is the person’s primary spoken language?	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
If other, what is primary spoken language?
Is there anything about the person’s identity that would be important for us to know?
*Address of the person being referred* (Street, City, State, ZIP)
*Phone # of the person being referred*
*Email address of the person being referred*
*Do you give us permission to contact the person by phone?*	Yes No
*Do you give us permission to leave a voicemail?*	Yes No
*Do you give us permission to contact the person by email?*	Yes No
*What is the insurance carrier and plan? (E.g., BCBS, MassHealth – Tyfts Health Together, etc.)*
*Is the person under the age of 18?	Yes No
*If under 18, does the legal guardian consent to this referral?	Yes No
*Does the person have a court-appointed legal guardian?*	Yes No
Include any contact information for someone who would know how to reach the person in case of an emergency (Name, email, cell phone number)
Does the person receive SSI/SSDI?	Yes No Don’t Know
Does the person have Mass Health?	Yes No Don’t Know
Does the person receive DMH services?	Yes No Don’t Know
1st Parent/Guardian Information (This section must be completed if the person is under 18.)
*1st Parent/Guardian Name*
*1st Parent/Guardian Address*
* 1st Parent/Guardian Phone #*
*1st Parent/Guardian Email*
*Do we have permission to leave a message or send email to parent/guardian?*	Yes No Don’t Know
*What is the 1st parent/guardian’s primary spoken language?*	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Don’t Know Other
If parent/guardian speaks another language not listed above, please describe.
2nd Parent/Guardian Information
*2nd Parent/Guardian Name*
*2nd Parent/Guardian Address*
*2nd Parent/Guardian Phone #*
*2nd Parent/Guardian Email*
*Do we have permission to leave a message or send email to parent/guardian?*	Yes No Don’t Know
*What is the 2nd parent/guardian’s primary spoken language?*	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Don’t Know Other
If parent/guardian speaks another language not listed above, please describe.
*Relationship of parents/guardians*	Married Separated Divorced Together, never married Not together DCF Custody Don’t Know Other
*Are both parents/guardians in agreement with this referral?*	Yes No
*Who has legal custody of the client?*	Both parents/guardians Parents/Guardian 1 only Parent/Guardian 2 only Neither parent/guardian DCF has custody
If neither parent/guardian has custody, please indicate who.
How did you learn about us?
How did you learn of our services?	General Practitioner Psychiatrist Pediatrician Non-Physicians (e.g. psychologist, social worker) Child & Youth Services (e.g. Child & Family Mental Health/Non-Mental Health Services, Youth Shelters) Community Agencies (e.g. Community Mental Health Center) Psychiatric Hospital or Dept. of Psychiatry within a Hospital Emergency/Urgent Care Post-Secondary School Mental Health & Counseling Services Secondary School (e.g. Guidance Counselor, School Psychologist, School Social Worker, etc.) First Episode Programs Addiction Services Family/Friend Self Other Co-worker Crisis Team (IE BEST) Neuropsychology Services DMH
Please provide name of provider/agency.
Reason for Referral
*What is leading the person to seek CEDAR services at this time?* (Please provide as much info as possible)
*Current and Previous Mental Health Diagnosis* (name, date of diagnosis, who made the diagnosis)
*Has the person started to experience any changes to their perception? (i.e. seeing/hearing/feeling/touching/tasting things that are not there)*	Yes No
If yes, when did it start and please briefly describe.
*Has the person started to notice any changes to their thinking or describe thought content that seems unusual? (i.e., saying that people are following or watching them, thinking that things in their surroundings have special meaning just for them)*	Yes No
If yes, when did it start and please briefly describe.
*Has the person experienced any recent changes in their thinking that make it difficult for them to communicate with others? (i.e., talking in a way that is hard for others to follow, etc)*	Yes No
If yes, when did it start and please briefly describe.
*Have there been any noticeable changes in the person’s relationships with friends or family over the past year?*
*Has the person’s ability to go to school and do their school work, or, if not a student, has the person’s ability to go to work and perform their job duties changed in any way in the past year?*
Current and Previous Care
*Has the person ever taken or are they currently taking any psychiatric medications?* (example: sertraline, for depression, 50mg per day)
How often are medications taken?	25% of the time 50% of the time 75% of the time 100% of the time Don’t Know
*Please list the names and contact information for each of the current providers (Therapist, School Counselor, IHT, Psychiatrist, etc.)
*Who is the person’s Primary Care Provider?*
*Primary Care Provider Phone, Practice Name, Address*
*Has the person ever been evaluated in an ER or by an emergency medical team (BEST)*	Yes No Don’t Know
If yes, please provide the dates and reason for each.
*Has the person ever been hospitalized on an inpatient unit and/or received residential, PHP, or IOP?*	Yes No Don’t Know
If yes, please provide the dates and reason for each.
*Has the person ever experienced suicidal ideation?*	Yes No Don’t Know
*Has the person ever engaged in self harm?*	Yes No Don’t Know
*Has the person ever been aggressive/harmed others?*	Yes No Don’t Know
*Has the person ever experienced any head injuries or neurological issues?*	Yes No Don’t Know
*Has the person ever used marijuana, alcohol, or other recreational drugs?*	Yes No Don’t Know
*Is the person currently using substances?*	Yes No Don’t Know
If yes, briefly describe what substance(s) the person uses.
*Does the person have or feel that they need any accommodations at school for learning reasons?*	Yes No Don’t Know
If yes, briefly describe need.
*Does the person have or feel that they need any accommodations at school for emotional support?*	Yes No Don’t Know
If yes, briefly describe need.
Family History
*Is there a diagnosed or suspected family history of psychosis? (i.e., schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, etc.)	Yes No
If yes, what is the person’s relationship with the family member?
Have you made referrals to other programs? If yes, please describe which programs.
Please fax any relevant medical records to 617-734-6385 and address them to the CEDAR Clinic. These may include Discharge summaries, Neuropsych evaluations, or other assessments.
Thank you for your referral to the CEDAR Clinic. We will reach out to you within 48 business hours. If you have questions in the meantime, please reach out to cedarclinic@brooklinecenter.org or 857-707-3478.