Date:     

Child's Name:       DOB:    

Phone:    SS#:

Address:

City:     

State:       Zip:

Mass Health ID#:    MCE coverage:

Parent/Caregiver's Name:   

Relationship to child:   

Is the family/guardian in agreement with this referral?  Yes    No    Not sure

Has the family been informed about what the service offers?  Yes    No    Not sure

School Name:    

Does the child have an IEP?  Yes    No    Not sure

AXIS I DX (required):

AXIS II DX (if applicable):

Date of last CANS assessment: 

Purpose of Therapeutic Mentoring:


Goals of Therapeutic Mentoring:


Desired time of TM (please indicate preferences and time)

Additional Referral Info:


Referred by:
(ICC/IHT/Out Patient Services)

Agency/Program:

Phone:         Cell:

*Please FAX/send a Treatment plan, Safety plan, Care plan, Behavioral Plan and CANS assessment to:

Child & Family Services, Inc.
Attention: Therapeutic Mentoring
800 Purchase St., 4th fl
New Bedford, MA  02740
Tel: 508-990-0894
FAX: 508-990-0298