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 Code Phone 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? *

Yes (please comment below) No
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? *

Yes No
Client Information
Parent/Caregiver's Full Name: *
Date of Birth: *
Sex: *

Male Female Transgender
Client's Street Address: *
City, State, and Zip Code (please include zip code): *
Home Phone: *

- Area Code Phone Number
Cell Phone:

- Area Code Phone 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? *

Yes (if yes, please see comment section below) No Not sure
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: *

Safety issues/DV in the home currently DCF involvement (investigation or open case) Current alcohol and/or other drug abuse Medical problems that are impacting mental health issues Current suicidal ideation (with or without a plan) Current homicidal ideation (wanting to hurt someone) Past homicidal ideation (has seriously hurt another person) History of alcohol and/or other drug abuse Past safety issues/DV in the home History of suicidal ideation (with or without a plan, suicidal attempts) None
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): *

Massachusetts Behavioral Health Partnership (MBHP)-an affiliation of Mass Health Blue Cross/Blue Shield Private pay/sliding scale fee arrangement
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