Referral for Services
Please complete entire referral with all requested information below; if not this referral may not be processed.

Phone numbers collected on this form are not shared, and not shared for SMS purposes,  however by completing this form you may receive informational text messages from Eliot CHS. you can opt-out at any time by replying STOP to the number.

Please fax any relevant HUB documents to 413-534-0047 (West) or 781-395-0198 (East)
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Region of Referral *
Child/Youth First Name *
Child/Youth Last Name: *
Gender
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Date of Birth *
MM
/
DD
/
YYYY
Current Address (Please include City, State and Zip) *
Person making Referral *
Organization making Referral
Referrer Relationship to Youth *
Referrer Phone Number *
I acknowledge by completing this form I may receive informational text messages from Eliot CHS. I can opt-out at any time by replying STOP to the number.
Referrer Email Address *
Have you submitted referrals to any other agencies?
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Legal Guardian's Full Name *
Legal Guardian Relationship to Youth:
Legal Guardian's Email Address
Legal Guardian's Phone Number *
I acknowledge by completing this form I may receive informational text messages from Eliot CHS. I can opt-out at any time by replying STOP to the number.
Insurance (include ALL insurance plans, commercial & public) *
Insurance Number - This must be provided *
Child/Youth/Family Strengths
Reason for Referral (Please provide detailed information around presenting symptoms, relevant history, and safety or risk concerns): *
Child/Youth Diagnosis/Diagnostic History
What is the Youth's/Family primary language?
What service are you seeking?
Family has consented to the referral? *
Required
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