Client Referral Form

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.

Please note that all fields with an * are required

Referral Information
*What is your legal name* (First and Last)
What name do you prefer
*Date of Birth*
*What is your sex assigned at birth* (female, male, intersex)
*What is your gender identity* (Woman, man, transmasculine, transfeminine, etc)
*What are your pronouns* (She/Her; He/Him; They/Them)
*What best describes your 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 you identify as another racial identity not listed.
*What best describes your sexual orientation?*	Heterosexual Gay Lesbian Bisexual Pansexual Queer Other Prefer not to say
Please fill in if you identify as another sexual orientation not listed
What is your 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 your identity that would be important for us to know?
*Address* (Street, State, ZIP)
*Phone #*
*Email*
*Do you give us permission to contact you by phone?*	Yes No
*Do you give us permission to leave a voicemail?*	Yes No
*Do you give us permission to contact you by email?*	Yes No
*What is your insurance carrier and plan (e.g., MassHealth – Tufts Health Together or BCBS)*
*Are you under the age of 18?	Yes No
*Do you (over 18 years old) or your legal guardian consent to this referral?	Yes No
*Do you have a court-appointed legal guardian?*	Yes No
Include any contact information for someone who would know how to reach you in the case of an emergency (Name, email, cell phone number)
Do you receive SSI/SSDI?	Yes No
Do you have Mass Health?	Yes No
Do you receive DMH services?	Yes No
1st Parent/Guardian Information, (You must complete if you are under 18. However, If you are over 18 years old, are you willing to have us speak to a parent/guardian? If yes, please provide the below information.)
*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
*What is the 1st parent/guardians primary spoken language?*	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
If Parent/guardian speaks another language not listed above
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
*What is the 2nd parent/guardians primary spoken language?*	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
If Parent/guardian speaks another language not listed above
*Relationship of parents/guardians*	Married Separated Divorced Together, never married Not together DCF Custody 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 you to seek CEDAR services at this time?* (Please provide as much info as possible)
*Current and Previous Diagnosis* (name, date of diagnosis and who made the diagnosis)
*Have you started to experience any changes to your 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.
*Have you started to notice any changes to their thinking, or describing 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.
*Have you experienced any recent changes in your thinking that make it difficult for you 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 your relationships with friends or family over the past year?*
*Has your ability to go to school and do your school work, or, if you are not a student, your ability to go to work and perform you job duties changed in anyway in the past year?*
Current and Previous Care
*Have you ever taken or 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
*Please list the names and contact information for each of your current providers (Therapist, School Counselor, IHT, Psychiatrist, ect)
*Who is your Primary Care Provider?*
*Primary Care Provider Phone, Practice Name, Address*
*Have you ever been evaluated in an ER or by an emergency medical team (BEST)*	Yes No
If yes, please provide the dates and reason for each.
*Have you ever been hospitalized on an inpatient unit and/or received residential, PHP, or IOP?*	Yes No
If yes, please provide the dates and reason for each.
*Have you ever experienced suicidal ideation?*	Yes No
*Have you ever engaged in self harm?*	Yes No
*Have you ever been aggressive/harmed others?*	Yes No
*Have you ever experienced any head injuries or neurological issues?*	Yes No
*Have you ever used marijuana, alcohol, or other recreational drugs?*	Yes No
*Are you currently using substances?*	Yes No
If yes, briefly describe what substance you uses.
*Do you have or feel that they need any accommodations at school for learning reasons?*	Yes No
If yes, briefly describe need.
*Do you have or feel that they need any accommodations at school for emotional support?*	Yes No
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 their relationship to you?
Have you made referrals to other programs, if yes, please describe which programs.
Please fax any relevant medical records to 857-557-5426. These may include Discharge summaries, Neuropsych evaluations, or other assessments
Thank you, we will reach out to you as soon as we can. If you have questions in the meantime please reach out to cedarclinic@brooklinecenter.org