TEST PAGE

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.

Referral information
Completed By	Client (Referring myself)
Do you have a court-appointed legal guardian?	Yes No
Who should we contact for follow up for the referral?
What is the role of the contact to follow up with? (Client, family, provider)
Please provide a phone # to follow up with
Please provide an email to follow up with
Client Information
Preferred name (First and Last)
Legal Name
Current Address (Street, State, ZIP)
Phone #
Email
Do you give us permission to contact you by phone?	Yes No
Do we have permission to leave a voicemail?	Yes No
Do we have permission to contact by email?	Yes No
Include name any contact information for in case of 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
Date of Birth
Sex assigned at birth
Gender
Preferred pronouns
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 A racial identity not listed here Prefer not to say
Race (Other)
What best describes your sexual orientation?	Heterosexual Gay Lesbian Bisexual Pansexual Queer None of these describe me Prefer not to say
What is your primary spoken language?	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
If other, what is your primary spoken language?
Is there anything about your identity that would be important for us to know?
Parent/Guardian 1 Information, Please complete if you would like to have a parent/guardian involved with our care.
Parent/Guardian Name 1
1st Parent/Guardian Address
Parent/Guardian Phone 1
Parent/Guardian Email 1
Do we have permission to leave a message or send email to parent/guardian 1?
What is the 1st parent/guardians primary spoken language?	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
Parent/guardian 1 language other?
Parent/guardian 1 occupation?
How much school did the 1st parent/guardian complete??
Is there a second parent guardian?	Yes No
Parent/Guardian 2 Information
Parent/Guardian Name 2
2nd Parent/Guardian Address
Parent/Guardian Phone 2
Parent/Guardian Email 2
Do we have permission to leave a message or send email to parent/guardian 2?
What is the 2nd parent/guardians primary spoken language?	English Spanish Portuguese Chinese (Mandarin) Chinese (Cantonese) French Arabic Haitian Creole Other
Parent/guardian 2 language other?
Parent/guardian 2 occupation?
How much school did the 2nd parent/guardian complete?
Relationship of parents/guardians	Married Separated Divorced Together, never married Not together Other
Are both parents/guardians in agreement with this referral?	Yes No
Does someone besides biological parents have custody of you?	Both parents/guardians Parents/Guardian 1 only Parent/Guardian 2 only Neither parent/guardian
If neither parent/guardian, please indicate who
Do any of the person’s caregivers receive benefits due to emotional/psychiatric disabilities	Yes No
How did you learn about us?
Name of Referral Provider
Referral Provider Phone #
Referral Provider Email
Role of referring provider
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.) Secondary Care: First Episode Programs Secondary Care: Addiction Services Family/Friend Self Other Unknown Invitation from Screening Co-worker Crisis Team (IE BEST) Neuropsychology Services DMH Referral Services (IE INTERFACE)
Please provide name of provider/agency
Who is your Primary Care Provider?
Primary Care Provider Phone, Practice Name, Address
Reason for Referral
If you are referring yourself and are 18 years or older, please list any family members that you are willing to have contacted for additional information (Name/Relationship/Phone/Email)
Do you grant us permission to contact any of your providers?
Please provide the name, email, and phone of all providers you grant us permission to contact
What are your presenting concerns? (Example; Began hearing voices March 2020. This has been distressing since September 2020 and makes it difficult to concentrate in school.) Please provide as much info as possible
Current and Previous Diagnosis (name, date of diagnosis and who made the diagnosis)
Any other difficulties that would be important for you to share at this time? — Please describe
Has there been a change in social functioning/connectedness over the last year (Withdrawn, isolating, not wanting friends)
Has there been a change in school/work performance over the last year? (Decrease in grades, difficulty keeping up with work?)
Family History
Do you have any family members who have experienced psychiatric and/or substance use difficulties?
Please indicate which relatives may have experienced psychiatric and/or substance use difficulties?
Please individually describe diagnosis or symptoms: (Example: Maternal Uncle – Schizophrenia)
Current and Previous Psychiatric Care
Current medications (And doses?) (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 describe any other mental health care currently received (Therapy, case management, psychiatry, ect)
Have you ever been treated in these levels of care?	Emergency Department Inpatient Mental Health Care Community Based Acute Treatment (CBAT) Partial Hospitalization Program (PHP) Residential Treatment Program Other
If Other Treatment, Where?
Treatment 1 (Please describe dates of care and reason for care)
Treatment 2 (Please describe dates of care and reason for care)
Treatment 3 (Please describe dates of care and reason for care)
Treatment 4 (Please describe dates of care and reason for care)
Treatment Other (Please use this to describe other mental health care received)
Have you ever been evaluated by BEST or the ER for psychiatric reasons?	Yes No
Please list dates and reasons
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

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