Clinician Referral Form

Please note that all fields with an * are required

Referral Provider Information
*Name of Referral Provider*
*Referral Provider Phone #*
*Referral Provider Email*
Role of Referring Provider
Where are you referring from?	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 enter the name of your agency or clinic.
Who is the client’s Primary Care Provider?
PCP Contact Information (Phone, Practice Name, Address)
Client Information
*Client’s legal name* (First and Last)
Client’s preferred name (First and Last)
*Client’s Date of Birth*
*Client’s sex assigned at birth* (female, male, intersex)
*Client’s gender* (Woman, man, transmasculine, transfeminine, etc.)
*Client’s preferred pronouns* (She/Her, He/Him, They/Them, etc.)
*What best describes the client’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 client identifies as another racial identity not listed.
*What best describes the client’s sexual orientation?*	Heterosexual Gay Lesbian Bisexual Pansexual Queer Other Prefer not to say
Please fill in if the client identifies as another sexual orientation not listed.
What is the client’s primary spoken language?	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
If other, what is the client’s primary spoken language?
Is there anything about the client’s identity that would be important for us to know?
*Client’s address* (Street, State, ZIP)
*Client’s phone #*
*Client’s email*
*Does the client give us permission to contact them by phone?*	Yes No
*Does the client give us permission to leave a voicemail?*	Yes No
*Does the client give us permission to contact them by email?*	Yes No
*Does the client or client’s legal guardian consent to this referral?	Yes No
*Does the client have a court-appointed legal guardian?*	Yes No
*If you’re referring for someone else, are they aware you are making this referral?*	Yes No
Include any contact information for someone who would know how to reach the client in case of emergency (Name, email, cell phone number)
Does the client receive SSI/SSDI?	Yes No
Does the client have Mass Health?	Yes No
Does the client receive DMH services?	Yes No
Parent/Guardian 1 Information
*Parent/Guardian Name 1*
*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 1?*	Yes No
*What is the 1st parent/guardian’s primary spoken language?*	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
If Parent/guardian 1 speaks another language not listed above
Parent/Guardian 2 Information
*Parent/Guardian Name 2*
*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 2?*	Yes No
*What is the 2nd parent/guardian’s primary spoken language?*	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
If Parent/guardian 2 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.
Reason for Referral
*What is leading the client 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)
*Has the client 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 client started to report 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 client 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 client’s relationships with friends or family over the past year?*
*Has the client’s ability to go to school and do their school work, or, if they are not a student, their ability to go to work and perform their job duties changed in any way in the past year?*
Current and Previous Care
*Has the client 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 the client’s current providers (Therapist, School Counselor, IHT, Psychiatrist, etc.)
*Has the client 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.
*Has the client 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.
*Has the client ever experienced suicidal ideation?*	Yes No
*Has the client ever engaged in self harm?*	Yes No
*Has the client ever been aggressive/harmed others?*	Yes No
*Has the client ever experienced any head injuries or neurological issues?*	Yes No
*Has the client ever used marijuana, alcohol, or other recreational drugs?*	Yes No
*Is the client currently using substances?*	Yes No
If yes, briefly describe what substance(s) the client uses.
*Does the client have or feel that they need any accommodations at school for learning reasons?*	Yes No
If yes, briefly describe need.
*Does the client 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 the client?
Have you made referrals to other programs? If yes, please describe which programs.
Please fax any relevant medical records to 617-734-6385. These may include Discharge summaries, Neuropsych evaluations, or other assessments.
Thank you, we will reach out to you within 48 business hours. If you have questions in the meantime please reach out to cedarclinic@brooklinecenter.org.