CEDAR Clinic

CEDAR Clinic

Helping Youth at Risk for Psychosis

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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 or 857-707-3478.

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, etc.)
*What best describes your racial identity?*
Please fill in if you identify as another racial identity not listed.
*What best describes your sexual orientation?*
Please fill in if you identify as another sexual orientation not listed.
What is your primary spoken language?
If other, what is primary spoken language?
Is there anything about your identity that would be important for us to know?
*Address* (Street, City, State, ZIP)
*Phone #*
*Email*
*Do you give us permission to contact you by phone?*
*Do you give us permission to leave a voicemail?*
*Do you give us permission to contact you by email?*
*What is your insurance carrier and plan (e.g., MassHealth – Tufts Health Together or BCBS)*
*Are you under the age of 18?
*Do you (over 18 years old) or your legal guardian consent to this referral?
*Do you have a court-appointed legal guardian?*
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?
Do you have Mass Health?
Do you receive DMH services?
1st Parent/Guardian Information (You must complete if you are under 18. 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?*
*What is the 1st parent/guardians primary spoken language?*
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?*
*What is the 2nd parent/guardians primary spoken language?*
If Parent/guardian speaks another language not listed above
*Relationship of parents/guardians*
*Are both parents/guardians in agreement with this referral?*
*Who has legal custody of the client?*
If neither parent/guardian has custody, please indicate who
How did you learn about us?
How did you learn of our services?
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 Mental Health 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)*
If yes, when did it start and please briefly describe.
*Have you started to notice any changes to your thinking, or describe thought content that seems unusual to you or others? (i.e., saying that people are following or watching you, thinking that things in your surroundings have special meaning just for you)*
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)*
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 your job duties changed in any way in the past year?*
Current and Previous Care
*Have you ever taken or are you currently taking any psychiatric medications?* (example: sertraline, for depression, 50mg per day)
How often are medications taken?
*Please list the names and contact information for each of your current providers (Therapist, School Counselor, IHT, Psychiatrist, etc.)
*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)?*
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?*
If yes, please provide the dates and reason for each.
*Have you ever experienced suicidal ideation?*
*Have you ever engaged in self harm?*
*Have you ever been aggressive/harmed others?*
*Have you ever experienced any head injuries or neurological issues?*
*Have you ever used marijuana, alcohol, or other recreational drugs?*
*Are you currently using substances?*
If yes, briefly describe what substance you uses.
*Do you have or feel that you need any accommodations at school for learning reasons?*
If yes, briefly describe need.
*Do you have or feel that you need any accommodations at school for emotional support?*
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.)
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 617-734-6385 and direct them to the CEDAR Clinic. These may include Discharge summaries, Neuropsych evaluations, or other assessments.
Thank you for your referral. 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.

The CEDAR Clinic is a clinical program of The Brookline Center for Community Mental Health and is affiliated with Beth Israel Deaconess Medical Center and Harvard Medical School.   

CEDAR is located at The Brookline Center for Community Mental health. Please see our directions page for more details. 

Clinic Location and Directions (cedarclinic.org)

www.brooklinecenter.org

41 Garrison Road, Brookline, Massachusetts, 02445

 

Email: cedarclinic@brooklinecenter.org