CEDAR Clinic Referral Form
This referral form is a request for either a CEDAR evalaution or services.
Please fill out this form to the best of your ability.
If you are having any difficulties we can be reached at
cedarclinic@brooklinecenter.org
Once you have completed this form, we will reach out to you by email or phone within 72 business hours to discuss next steps.
* Indicates required fields.
If you are under the age of 18, you must complete information about one gaurdian or caregiver
| *Relationship of parents/guardians* | |
| *Are both parents/guardians in agreement with this referral?* | |
| *Who has legal custody of the client?* | |
| *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? | |
Please complete if there is a second gaurdian or caregiver
| *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/gaurdians primary spoken language? | |
Referral Reason and Information
| *What is leading you to seek CEDAR services at this time?* | |
| *Current and Previous Diagnosis* | |
| *Have you started to experience any changes to your perception? | |
| *Have you started to notice any changes to their thinking, or describing thought content that seems unusual? | |
| *Have you experienced any recent changes in your thinking that make it difficult for you to communicate with others? | |
| *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 Mental/Physical Health Care
| *Have you ever taken or currently taking any psychiatric medications?*> | |
| How often are medications taken? | |
| *Please list the names and contact information for each of your current providers. | |
| *Who is your Primary Care Provider?* | |
| *Primary Care Provider Phone, Practice Name, Address* | |
| *Last time your were seen by your primary care provider* | |
| *Have you ever been seen by a neurologist?* | |
| *Have you ever been evaluated in an ER or by an emergency medical team (BEST)?* | |
| *Have you ever been hospitalized on an inpatient unit and/or received residential, PHP, or IOP?* | |
| *Have you ever experienced suicidal ideation?* | |
| *Have you ever engaged in self harm?* | |
| *Have you ever been aggressive/harmed others?* | |
| *Have you ever used marijuana, alcohol, or other recreational drugs?* | |
| *Are you currently using substances?* | |
| *Do you have or feel that you need any accommodations at school for learning reasons?* | |
| *Do you have or feel that you need any accommodations at school for emotional support?* | |
| Family History | |
|---|---|
| *Is there a diagnosed or suspected family history of psychosis? | |
| Have you made referrals to other programs, if yes, which programs. | |
| How did you learn of our services? | |
| 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 as soon as we can. If you have questions in the meantime please reach out to
cedarclinic@brooklinecenter.org |
