Safe Kids-Healthy Families Referral Form

Merrimack Valley Trauma Services

Safe Kids-Healthy Families Referral Form
Important Note: Please use this form for Safe Kids-Healthy Families referrals only. Please do not use this form for therapy referrals for children. Safe Kids-Healthy Families is billed through parents/caregivers. If you would like to make a referral for therapy for a child, please use the MVTS Referral Form for Therapy. Thank you!
Referral Source (If self-referral, skip this section and continue onto "Client Information"):
Name of person making the referral:
Name of Agency/Program:
Phone Number:

Area CodePhone Number
Email Address:
Your relationship to the person you are referring (e.g., DCF worker, child's therapist, case manager):
Is this parent/caregiver's involvement in Safe Kids-Healthy Families mandated?
If the parent/caregiver's involvement is mandated, please specify (DCF recommended, court-ordered, etc.):
Has the consumer signed a release so that MVTS can communicate with you about his/her treatment?
Client Information
Parent/Caregiver's Full Name:
Date of Birth:
Sex:
Client's Street Address:
City, State, and Zip Code (please include zip code):
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Email Address:
Language(s) Spoken:
Marital Status:
Reason for Referral (please include a brief history of sexual abuse in the family, who will be participating in the program, and what the parent would like to learn from this program):
Treatment Providers Involved
Is the parent/caregiver currently seeing another therapist?
If the parent/caregiver is currently seeing another therapist, please provide the counselor's name and contact information:
Please list all other providers involved with the family, including in-home therapists, case managers, and children's providers. (Please include their name, contact information, and services provided.)
Name of primary care physician, practice name, and phone number:
Current Medications(if known):
Allergies (if known):
Current and Past Risk Factors
Please check all that apply and include comments at the end of the question:
Please comment if you checked any of the risk factors above:
Insurance/Payment Information
Please note that we do not accept straight Mass Health or secondary insurance.
If you checked "Private pay/sliding scale fee arrangement," we will contact you to discuss a payment arrangement.
Insurance Type (Check one):
Insurance ID#
If BCBS, please list the policy holder's name & D.O.B.:
Appointments, Requests, How Did You Hear
Best days and times for appointments:
Special requests or comments:
How did you hear about the Safe Kids-Healthy Families Program?
Should be Empty:

Merrimack Valley Trauma Services

Referral Source (If self-referral, skip this section and continue onto "Client Information"):

Client Information

Treatment Providers Involved

Current and Past Risk Factors

Insurance/Payment Information

Appointments, Requests, How Did You Hear