TJCC General Referral Form for Adults

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CLIENT INFORMATION

Name *

First

Last

Gender *

• Male
• Female

Date of Birth (DOB) *

Age *

Social Security #: *

MMIS # *

Phone *

Payer Type: *

• MBHP
• BMC
• Private/Other

Policy #: *

Contact/Guardian Name: *

First

Last

Relation to Client: *

Phone *

Address *

Address Line 1

City

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Members of Household *

Primary Language *

Secondary Language *

Email *

REFERRER INFORMATION

Referral Name, Agency & Phone # *

DCF Worker Name, Office & Phone # *

Availability *

• Daytime
• Afternoon
• Evening
• Weekday
• Weekend
• Other

Availability (Other)

Is client willing to engage in telehealth services? *

• Yes
• No

Prior/Current Treatment or Services: *

Axis 1 Diagnosis: *

Other Providers

Substance Use Counselor Name

First

Last

Phone

Agency

Psychiatry Name

First

Last

Phone Number

Agency

Therapist Name

First

Last

Phone Number

Agency

Other Name

First

Last

Phone Number

Agency

Significant Impairment in Functioning: *

• Home
• Work
• Relationships
• Other/Legal/Community:

Significant Impairment in Functioning: (Other)

Reason for Referral *

RISK FACTORS OR SAFETY CONCERNS

Check All that apply: *

• Suicide Ideation
• Suicide Gestures
• Self-Injurious Behavior
• Homicidal Ideations
• Current Substance Use
• History of Substance Use
• Impulsive Behavior
• Violence/Aggression Towards Others
• Lack of Social Group
• Gang Involvement
• Sexualize Aggression/Behavior
• Takes Dangerous Risks
• Fire-setting
• Work Impairment/loss
• Isolation Behavior
• Trauma History
• Medical/Physical Issues
• Compulsive behavior
• Not Medication Compliant
• In-Home Issues
• Lack of Natural Support
• Housing Instability
• Mental Health Diagnosis:
• Other:

Mental Health Diagnosis:

Other :

CAREGIVER RISK FACTORS

Primary Support’s Risk Factors: *

Check All that apply: *

• Current Substance Use
• History of Substance Use
• Not Medication Compliant
• Housing Instability
• Financial Distress
• Current Domestic Violence
• History of Domestic Violence
• Medical / Physical Issues
• Unable/Unwilling to Provide Natural Supports
• Lack of Natural Supports
• Other:

Other :

Please provide any additional information that may be relevant to assist us in meeting your needs and those of your partner. If you are seeking couple or marriage counseling, please provide demographic information about your spouse/partner.

Other Information

Terms of Use *

• Yes, I want to submit this form By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold TJocelyne Counseling and Consulting Clinic LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Submit

425 Pleasant Street

First Floor suite 102

Brockton, MA 02301

Call:  (508) 580-0364

Email: intake@tjocelyne.org

Send Your Question...

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Name *

First

Last

Phone *

Email *

Comment or Message *

Terms of Use *

• Yes, I want to submit this form By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold TJocelyne Counseling and Consulting Clinic LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Submit