Please fill out this form to the best of your ability. If you are having any difficulties we can be reached at mpath@brooklinecenter.org or (617) 927-9809.

Once you have completed this form, we will reach out to you using the contact information you've submitted below to discuss next steps.

* Indicates required fields.

*What is your first name?

*What is your last name?

What are your pronouns?

He/Him She/Her They/Them Something Else

Enter here if "Something Else":

*Where are you referring the client from?

Health care provider (e.g., primary care doctor/pediatrician) Mental health care provider (e.g., psychiatrist, psychologist, mental health counselor, social worker) Call center/support center (Interface, 988, Behavioral Health Help Line) Middle or high school College or university Hospital/emergency department Family/friend Internet search Department of Youth Services/Department of Corrections Other

Enter here if "Other":

*How did you hear about our services?

Health care provider (e.g., primary care doctor/pediatrician) Mental health care provider (e.g., psychiatrist, psychologist, mental health counselor, social worker) Call center/support center (Interface, 988, Behavioral Health Help Line) Middle or high school College or university Hospital/emergency department Family/friend Internet search Department of Youth Services/Department of Corrections Other

Enter here if "Other":

*What is your relationship to the client?

Outpatient Therapist Outpatient Prescriber Inpatient Therapist Inpatient Social Worker Inpatient Prescriber Emergency Department Clinician Primary Care Physician Pediatrician School-Based Clinician Referral Service (Ex: INTERFACE/BHHL) Other

Enter here if "Other":

*What organization are you referring from?

*Is the client aware that you're making this referral?

Yes No Unsure

*Is the parent/legal guardian aware that you're making
this referral?

Yes No Unsure

*What is your phone number?

*Can we leave a voicemail?

Yes No

What is your email address?

When is the best time to contact you?

What is your preferred method of contact?

Phone Email Phone and Email

*What is your client's age?

*What is your client's ZIP code?

*What is the primary reason you're contacting us?

I would like more information about psychosis I am seeking consultation about symptoms my client is experiencing I am seeking support in finding a referral for early psychosis treatment for a client of mine Other

Enter here if "Other":

*What is leading you to seek support from M-PATH at this time?
(Please provide as much info as possible)

Is there anything else that would be helpful for us
to know when contacting and working with the
client and family? (e.g. translation services,
accommodation for a disability, need for phone-
based services, etc)

.