Safe Kids-Healthy Families Referral Form Logo
  • Merrimack Valley Trauma Services

    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"):

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  • Client Information

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  • Treatment Providers Involved

  • Current and Past Risk Factors

  • 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
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  • Appointments, Requests, How Did You Hear

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  • Should be Empty: