PRIDE In-Home Therapy (IHT) Referral Form

PRIDE In-Home Therapy (IHT) Referral Form
Our inclusive PRIDE Team consists of highly qualified mental health professionals and paraprofessionals who are a part of the LGBTQIA+ community. Our PRIDE Team is thoughtful in our choice of respectful language, behaviors, and continued education to best reflect the current needs and expectations of the LGBTQIA+ community."
Date of Referral:*

MonthDayYear
Date
Client's Legal Name:*

First NameLast Name
Client's Affirmed Name:*
Client's Gender Identity:*

Man or Boy (CIS)Woman or Girl (CIS)Transgender Man or Boy/Trans Man/MasculineTransgender Woman or Girl/Trans Woman/FeminineGenderqueer/Gender Expansive/Nonbinary/Neither Exclusively Male nor Female
Client's Date of Birth:*

MonthDayYear
Date
Client's Age:*
Client's Primary Language:*
Client's Preferred Language:*
Would client be interested in the Multicultural Outreach Team? (Specialty clinical - team focusing on multicultural youth and families - current language available is Spanish):*

YesNo
Other Languages Spoken:*
Insurance ID:*
Primary Insurance Type:*

MassHealth - BeaconMassHealth - TuftsMassHealth - MBHPBCBSTufts (Commercial)Beacon (Commerical)Optum (Harvard Pilgrim)Optum (United HealthCare)Optum (UBH)Other
For Above Enter Other information and/or which BCBS State (i.e. BCBSRI, BCBSMA, etc.):
If able please upload a picture of the front and back of your insurance card

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Guardian(s) Name:

First NameLast Name
Guardian's Relationship to Client:
Parent Name (if different):

First NameLast Name
Client/Guardian's Phone Number:*
Please enter a valid phone number.
Client/Guardian's Email:
example@example.com
Client/Guardian's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Members of Household:*
DCF Worker:

First NameLast Name
DCF Worker Phone Number:
Please enter a valid phone number.
Please Identify if DCF custody is:

CRALegal
Referent Name:*

First NameLast Name
Referring Agency:*
Referent Phone Number:*
Please enter a valid phone number.
Referent Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If ICC - Have the IHT service units been authorized?

YesNo
Has an IHT referral been placed to other agencies?*

YesNo
If Yes, Which Agencies:
Has the family received IHT services previously?*

YesNo
If Yes, Which Agency? When? Reason for Termination:
Preference for Scheduling (include days and times):*
Have you spoken to the client about this referral?*

YesNo
Has the client voluntarily agreed to this referral?*

YesNo
Please list all Psychiatric Hospitalizations, Crisis Visits, or Risk Assessments that have occurred in the past (1) one year:*
Risk for Re-Hospitalization (1= very low, 3=moderate, 5=very likely):*

12345
*
Other Current Providers (CSA, Psychiatry, Individual Therapist, etc.): please list Name, Service, Agency & Phone Number*
Reason for Referral/Goals: (symptoms, behavioral/social/emotional functioning of youth/family, focus of treatment. Please also include information regarding reasons this family/client would benefit from working with our Pride team):*
Reason IHT Level of Care needed (please choose all that apply):*

Outpatient services alone are not sufficient to meet youth and family's needs for clinical interventionNeed for increased frequency/duration/flexibility of family sessions depending on need in the home and communityNeed for 24/7 urgent telephonic response and risk management/safety planningYouth at risk for out-of-home placementNeed for care coordination with school, other providers, state agencies, natural supports, etc.Need treatment to enhance youth's problem-solving, limit setting, and communication to sustain youth in homeStrengthen caregiver(s) ability to sustain youth in home
Client At-Risk Factors Present (please choose all that apply):*

Suicidal IdeationsSuicidal GesturesSelf-Injurious Behavior (cutting, burning, etc.)Homicidal IdeationsCurrent Substance UseHistory of Substance AbuseRunning AwayViolence/Aggression towards othersLack of Social GroupIsolatesSchool RefusalGang InvolvementSexualized Aggression/BehaviorSexual PromiscuityTakes Dangerous RisksFire-SettingNot Medication CompliantMedical/Physical (please explain below)Trauma History (please explain below)Other (please explain below)
Explain Client Medical/Physical Issues, Trauma History or Other At-Risk Factors Present:
Caregiver At-Risk Factors Present (please choose all that apply):*

Current Substance UseHistory of Substance UseNot Medication CompliantHousing InstabilityFinancial DistressCurrent Domestic ViolenceHistory of Domestic ViolenceUnable/Unwilling to Provide Adequate SupervisionLack of Natural SupportsMental Health Diagnoses - In Treatment? (please explain below)Medical/Physical Issues (please explain below)Other (please explain below)None
Explain Caregiver Mental Health Diagnoses (include if in treatment), Medical/Physical Issues or Other At-Risk Factors Present:
Identify which Caregiver the At-Risk Factors apply to:
Safety Concerns for Home-Based Clinician to Plan For:*

Unsafe NeighborhoodCurrent Domestic ViolenceViolent Family Member or Person Involved with Family (please describe below)Lack of Safe Parking AvailableAggressive AnimalsSuspected Illegal Substances in HomeWeapons in HomeNone
Provide details on Violent Family Member or Person Involved Involved with Family:
File Upload

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