Request for adult services effective October 2009



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Commonwealth of Massachusetts Department of Mental Health
REQUEST FOR ADULT SERVICES Effective October 2009 (Revised Oct 2015)
DMH Mission:

The Department of Mental Health (DMH) provides services and supports to individuals with serious and persistent mental illness to enable them to live independently in the community.


How to Request DMH Service(s):

Individuals 18 years of age or older who request mental health services through DMH must submit the following completed forms, with signatures and dates where indicated:




  • Request for Adult Services application.

  • Authorization(s) for Release of Information (see page 8)

Although additional information is not required at the time of a request for services, DMH encourages applicants to submit available medical/psychiatric information. It is strongly recommended the information be submitted at the same time as the application to expedite the determination process. Such additional information includes:




  • Outpatient psychiatric records and testing, and

  • Hospital admission and discharge reports.


Provider Instructions:

A provider assisting with an application to DMH must confirm the individual or guardian has been informed of, and does not object to, the submission of the application. The following clinical information must be included:




  • Psychiatric evaluation, including DSM diagnoses,

  • Any available assessments (e.g., psychosocial, medication, neuropsychological testing, etc.),

  • Any available admission and discharge summaries,

  • Current treatment plan, and

  • Authorization(s) for Release of Information (see page 10)

DMH may require additional clinical information as necessary.


What To Expect After You Submit an Application:

Within seven (7) days of receipt of a Request for Adult Services application, DMH will contact the applicant or guardian by telephone. The purpose of the phone contact will be to:




  • Acknowledge DMH’s receipt of the Request for Adult Services application,




  • Review the determination process,




  • Confirm the applicant or guardian wants to continue the determination process,




  • Assess the applicant’s immediate or emerging needs and respond as appropriate, and




  • Initiate the collection of relevant medical and other information that supports the applicant’s request for services.

A DMH Clinical Service Authorization Specialist may require, as necessary, a face-to-face meeting with the applicant and/or guardian to further discuss and assess the needs of the applicant. In most instances, a face-to-face meeting will occur at a DMH office. In other instances, a face-to-face meeting may occur at another agreed upon location.


The DMH Area Director or designee will make decisions regarding service requests upon receiving and reviewing information in accordance with DMH regulations http://www.mass.gov/eohhs/docs/dmh/regs/reg-104cmr29.pdf.
If an individual is found to meet the clinical criteria for services, the Area Director or designee must determine whether the individual needs DMH services. Since the availability of DMH services is limited, DMH must prioritize to whom and how those services are provided. DMH regulations establish the criteria to be used to determine who is authorized to receive DMH services and how those services are assigned.
Commonwealth of Massachusetts Department of Mental Health
REQUEST FOR ADULT SERVICES Effective October 2009 (Revised Oct 2015)
Where to find Application and Authorizations for Release of Information forms:

Request for Adult Services Applications and Authorization(s) for Release of Information are available in English, Spanish, Haitian, and Portuguese in all DMH Area and Site Offices, acute inpatient psychiatric facilities, in many community programs throughout the Commonwealth and can be downloaded from the DMH website at www.mass.gov/dmh. DMH can provide translators for other languages if necessary, and provide other assistance as needed.
Application Requirements:

A signed and dated Request for Adult Services application and Authorization for Release of Information forms must be delivered, mailed or faxed to the DMH Area or Site Office with responsibility for the community where the applicant resides at the time of application.



Where to send the Request for Adult Services:

Please find your city or town in the list that appears on the following pages, and send your application to the respective DMH Office in the list below. Please call the number listed if you have any questions.




Office

Mailing Address

Phone Number

Fax Number

Boston

85 East Newton Street, Boston, MA 02118

(617) 626-9200

(617) 626-9216

Brockton

165 Quincy Street, Brockton, MA 02302

(508) 897-2000

(508) 897-2047

Northampton

1 Prince Street, Northampton, MA 01060

(413) 587-6200

(413) 587-6240

Tewksbury

P.O. Box 387, Tewksbury, MA 01876-0387

(978) 863-5000

(978) 863-5091

Worcester

361 Plantation St. Worcester, MA 01605

(774) 420-3140

(774) 420-3165

Applications should NOT be sent to the DMH Central Office on Staniford Street in Boston. Doing so will result in misdirected applications, and may cause delays in the decision process.


Please contact the DMH Information and Referral Line at 1-800-221-0053 (Monday through Friday, 9am – 5pm) if you have questions about the application process or need information about where an application should be sent.
Commonwealth of Massachusetts Department of Mental Health (DMH)
REQUEST FOR ADULT SERVICES Effective October 2009 (Revised Oct 2015)


City or Town

DMH Office

City or Town

DMH Office

City or Town

DMH Office

City or Town

DMH Office

Abington

Brockton

Boston - Hyde Park

Boston

Danvers

Tewksbury

Hadley

Northampton

Acton

Tewksbury

Boston-Jamaica Plain

Boston

Dartmouth

Brockton

Halifax

Brockton

Acushnet

Brockton

Boston - Mattapan

Boston

Dedham

Worcester

Hamilton

Tewksbury

Adams

Northampton

Boston - North End

Boston

Deerfield

Northampton

Hampden

Northampton

Agawam

Northampton

Boston - Revere

Boston

Dennis

Brockton

Hancock

Northampton

Alford

Northampton

Boston - Roslindale

Boston

Dennisport

Brockton

Hanover

Brockton

Allston

Boston

Boston - Roxbury

Boston

Dighton

Brockton

Hanson

Brockton

Amesbury

Tewksbury

Boston - Somerville

Boston

Dorchester

Boston

Hardwick

Worcester

Amherst

Northampton

Boston - South End

Boston

Douglas

Worcester

Harvard

Worcester

Andover

Tewksbury

Boston - Southie

Boston

Dover

Worcester

Harwich

Brockton

Aquinnah

Brockton

Boston – W. Roxbury

Boston

Dracut

Tewksbury

Harwichport

Brockton

Arlington

Tewksbury

Boston - Winthrop

Boston

Dudley

Worcester

Hatfield

Northampton

Ashburnham

Worcester

Bourne

Brockton

Dunstable

Tewksbury

Haverhill

Tewksbury

Ashby

Worcester

Boxborough

Tewksbury

Duxbury

Brockton

Hawley

Northampton

Ashfield

Northampton

Boxford

Tewksbury

East Boston

Boston

Heath

Northampton

Ashland

Worcester

Boylston

Worcester

E. Bridgewater

Brockton

Hingham

Brockton

Assonet

Brockton

Bradford

Tewksbury

East Brookfield

Worcester

Hinsdale

Northampton

Athol

Northampton

Braintree

Brockton

E. Longmeadow

Northampton

Holbrook

Brockton

Attleboro

Brockton

Brewster

Brockton

East Sandwich

Brockton

Holden

Worcester

Auburn

Worcester

Bridgewater

Brockton

Eastham

Brockton

Holland

Worcester

Avon

Brockton

Brighton

Boston

Easthampton

Northampton

Holliston

Worcester

Ayer

Worcester

Brimfield

Worcester

Easton

Brockton

Holyoke

Northampton

Back Bay

Boston

Brockton

Brockton

Edgartown

Brockton

Hopedale

Worcester

Baldwinville

Worcester

Brookfield

Worcester

Egremont

Northampton

Hopkinton

Worcester

Barnstable

Brockton

Brookline

Boston

Erving

Northampton

Hubbardston

Worcester

Barre

Worcester

Buckland

Northampton

Essex

Tewksbury

Hudson

Worcester

Beacon Hill

Boston

Burlington

Tewksbury

Everett

Tewksbury

Hull

Brockton

Becket

Northampton

Buzzards Bay

Brockton

Fairhaven

Brockton

Huntington

Northampton

Bedford

Tewksbury

Byfield

Tewksbury

Fall River

Brockton

Hyannis

Brockton

Belchertown

Northampton

Cambridge

Boston

Falmouth

Brockton

Hyde Park

Boston

Bellingham

Worcester

Canton

Worcester

Fenway

Boston

Ipswich

Tewksbury

Belmont

Tewksbury

Carlisle

Tewksbury

Fiskdale

Worcester

Jamaica Plain

Boston

Berkeley

Brockton

Carver

Brockton

Fitchburg

Worcester

Jefferson

Worcester

Berlin

Worcester

Charlemont

Northampton

Florida

Northampton

Kingston

Brockton

Bernardston

Northampton

Charlestown

Boston

Foxborough

Worcester

Lakeville

Brockton

Beverly

Tewksbury

Charlton

Worcester

Framingham

Worcester

Lancaster

Worcester

Billerica

Tewksbury

Chatham

Brockton

Franklin

Worcester

Lanesborough

Northampton

Blackstone

Worcester

Chelmsford

Tewksbury

Freetown

Brockton

Lawrence

Tewksbury

Blandford

Northampton

Chelsea

Boston

Gardner

Worcester

Lee

Northampton

Bolton

Worcester

Cherry Valley

Worcester

Gay Head

Brockton

Leicester

Worcester

Bondsville

Northampton

Cheshire

Northampton

Georgetown

Tewksbury

Lenox

Northampton

Boston - Allston

Boston

Chester

Northampton

Gilbertville

Worcester

Leominster

Worcester

Boston - Back Bay

Boston

Chesterfield

Northampton

Gill

Northampton

Leverett

Northampton

Boston - Beacon Hill

Boston

Chicopee

Northampton

Gloucester

Tewksbury

Lexington

Tewksbury

Boston - Brighton

Boston

Chilmark

Brockton

Goshen

Northampton

Leyden

Northampton

Boston - Brookline

Boston

Clarksburg

Northampton

Gosnold

Brockton

Lincoln

Tewksbury

Boston - Cambridge

Boston

Clinton

Worcester

Grafton

Worcester

Linwood

Worcester

Boston-Charlestown

Boston

Cohasset

Brockton

Granby

Northampton

Littleton

Tewksbury

Boston - Chelsea

Boston

Colrain

Northampton

Granville

Northampton

Longmeadow

Northampton

Boston - Chinatown

Boston

Concord

Tewksbury

Great Barrington

Northampton

Lowell

Tewksbury

Boston - Dorchester

Boston

Conway

Northampton

Green Harbor

Brockton

Ludlow

Northampton

Boston - Downtown

Boston

Cotuit

Brockton

Greenfield

Northampton

Lunenburg

Worcester

Boston - East

Boston

Cummington

Northampton

Groton

Worcester

Lynn

Tewksbury

Boston - Fenway

Boston

Dalton

Northampton

Groveland

Tewksbury

Lynnfield

Tewksbury


Commonwealth of Massachusetts Department of Mental Health (DMH)
REQUEST FOR ADULT SERVICES Effective October 2009 (Revised Oct 2015)


City or Town

DMH Office

City or Town

DMH Office

City or Town

DMH Office

City or Town

DMH Office

Malden

Tewksbury

North Truro

Brockton

Sandisfield

Northampton

Wales

Worcester

Manchester

Tewksbury

Northampton

Northampton

Sandwich

Brockton

Walpole

Worcester

Manomet

Brockton

Northborough

Worcester

Saugus

Tewksbury

Waltham

Tewksbury

Mansfield

Brockton

Northbridge

Worcester

Savoy

Northampton

Ware

Northampton

Marblehead

Tewksbury

Northfield

Northampton

Scituate

Brockton

Wareham

Brockton

Marion

Brockton

Norton

Brockton

Seekonk

Brockton

Warren

Worcester

Marlborough

Worcester

Norwell

Brockton

Sharon

Worcester

Warwick

Northampton

Marshfield

Brockton

Norwood

Worcester

Sheffield

Northampton

Washington

Northampton

Marston Mills

Brockton

Oak Bluffs

Brockton

Shelburne

Northampton

Watertown

Tewksbury

Martha’s Vineyard

Brockton

Oakham

Worcester

Sherborn

Worcester

Wayland

Worcester

Mashpee

Brockton

Onset

Brockton

Shirley

Worcester

Webster

Worcester

Mattapan

Boston

Orange

Northampton

Shrewsbury

Worcester

Wellesley

Worcester

Mattapoisett

Brockton

Orleans

Brockton

Shutesbury

Northampton

Wellfleet

Brockton

Maynard

Tewksbury

Osterville

Brockton

Somerset

Brockton

Wendell

Northampton

Medfield

Worcester

Otis

Northampton

Somerville

Boston

Wenham

Tewksbury

Medford

Tewksbury

Oxford

Worcester

South Boston

Boston

West Barnstable

Brockton

Medway

Worcester

Palmer

Northampton

South Hadley

Northampton

West Boylston

Worcester

Melrose

Tewksbury

Paxton

Worcester

South Wellfleet

Brockton

West Bridgewater

Brockton

Mendon

Worcester

Peabody

Tewksbury

South Yarmouth

Brockton

West Brookfield

Worcester

Merrimac

Tewksbury

Pelham

Northampton

Southampton

Northampton

West Newbury

Tewksbury

Methuen

Tewksbury

Pembroke

Brockton

Southborough

Worcester

West Roxbury

Boston

Middleborough

Brockton

Pepperell

Worcester

Southbridge

Worcester

West Springfield

Northampton

Middlefield

Northampton

Peru

Northampton

Southwick

Northampton

West Stockbridge

Northampton

Middleton

Tewksbury

Petersham

Northampton

Spencer

Worcester

West Tisbury

Brockton

Milford

Worcester

Phillipston

Northampton

Springfield

Northampton

West Yarmouth

Brockton

Millbury

Worcester

Pittsfield

Northampton

Sterling

Worcester

Westborough

Worcester

Millers Falls

Northampton

Plainfield

Northampton

Stockbridge

Northampton

Westfield

Northampton

Millis

Worcester

Plainville

Worcester

Stoneham

Tewksbury

Westford

Tewksbury

Millville

Worcester

Plymouth

Brockton

Stoughton

Brockton

Westhampton

Northampton

Milton

Brockton

Plympton

Brockton

Stow

Tewksbury

Westminster

Worcester

Monroe

Northampton

Pocasset

Brockton

Sturbridge

Worcester

Weston

Worcester

Monson

Northampton

Princeton

Worcester

Sudbury

Worcester

Westport

Brockton

Montague

Northampton

Provincetown

Brockton

Sunderland

Northampton

Westwood

Worcester

Monterey

Northampton

Quincy

Brockton

Sutton

Worcester

Weymouth

Brockton

Montgomery

Northampton

Randolph

Brockton

Swampscott

Tewksbury

Whately

Northampton

Mt Washington

Northampton

Raynham

Brockton

Swansea

Brockton

White Horse Bch

Brockton

Nahant

Tewksbury

Reading

Tewksbury

Taunton

Brockton

Whitinsville

Worcester

Nantucket

Brockton

Rehoboth

Brockton

Teaticket

Brockton

Whitman

Brockton

Natick

Worcester

Revere

Boston

Templeton

Worcester

Wilbraham

Northampton

Needham

Worcester

Richmond

Northampton

Tewksbury

Tewksbury

Williamsburg

Northampton

New Ashford

Northampton

Rochdale

Worcester

Thorndike

Northampton

Williamstown

Northampton

New Bedford

Brockton

Rochester

Brockton

Three Rivers

Northampton

Wilmington

Tewksbury

New Braintree

Worcester

Rockland

Brockton

Tisbury

Brockton

Winchendon

Worcester

New Marlborough

Northampton

Rockport

Tewksbury

Tolland

Northampton

Winchester

Tewksbury

New Salem

Northampton

Roslindale

Boston

Topsfield

Tewksbury

Windsor

Northampton

Newbury

Tewksbury

Rowe

Northampton

Townsend

Worcester

Winthrop

Boston

Newburyport

Tewksbury

Rowley

Tewksbury

Truro

Brockton

Woburn

Tewksbury

Newton

Worcester

Roxbury

Boston

Turners Falls

Northampton

Wollaston

Brockton

Norfolk

Worcester

Royalston

Northampton

Tyngsborough

Tewksbury

Woods Hole

Brockton

North Adams

Northampton

Russell

Northampton

Tyringham

Northampton

Worcester

Worcester

North Andover

Tewksbury

Rutland

Worcester

Upton

Worcester

Worthington

Northampton

North Attleboro

Brockton

Sagamore

Brockton

Uxbridge

Worcester

Wrentham

Worcester

North Brookfield

Worcester

Salem

Tewksbury

Vineyard Haven

Brockton

Yarmouth

Brockton

North Reading

Tewksbury

Salisbury

Tewksbury

Wakefield

Tewksbury

Yarmouthport

Brockton


Commonwealth of Massachusetts Department of Mental Health (DMH)
REQUEST FOR ADULT SERVICES Effective October 2009 (Revised Oct 2015)

Race and Ethnicity Categories:

Race and Ethnicity information is requested so that DMH may better provide person-centered services that are culturally and linguistically appropriate. It also helps the Department comply with regulations and standards, and allows for the planning of unmet service needs.


Providing information about Race and Ethnicity is optional. Your decision to do so, or not to do so, will not affect your application for DMH services in any way.
The following options may be used to complete the “Race” and “Ethnicity” categories on the Request for Adult Services. In filling out the application, persons who are of more than one race or ethnicity are invited to identify as such.
RACE

The following designations come from the federal government:





Race Options

Black OR African American

Asian

Black/Hispanic

American Indian/Alaska Native

Chooses Not To Self-Identify

Other

Native Hawaiian or other Pacific Islander

Two or More Races

Unknown

White/Hispanic

White/Non-Hispanic


ETHNICITY

Ethnicity is defined as the group of people who you are connected to by a common national origin, history, ancestry, language or customs and cultural experiences. The following list is provided to show some examples of ethnicities or ethnic groups, and is not meant to be a complete listing.




Ethnicity Examples

Albanian

Greek

Pakistani

American - USA

Guatemalan

Peruvian

Armenian

Haitian

Panamanian

Bhutanese

Hispanic, Other

Polish

Bosnian

Hmong

Portuguese

Brazilian

Honduran

Puerto Rican

Burmese

Indian

Russian

Cambodian

Iranian

Salvadoran

Canadian

Iraqi

Somali

Cape Verdean

Irish

Thai

Chinese

Israeli

Tibetan

Colombian

Italian

Ukrainian

Congolese

Japanese

Unknown

Costa Rican

Korean

Venezuelan

Dominican

Laotian

Vietnamese

Egyptian

Lebanese

West Indian/Caribbean

Eritrean

Mexican




Ethiopian

Moroccan

Two or More Ethnicities

Filipino

Nigerian

Other

French

Nicaraguan

Chooses Not To Self-Identify

Commonwealth of Massachusetts Department of Mental Health (DMH)




REQUEST FOR ADULT SERVICES Effective October 2009 (Revised Oct 2015)


Name SSN

(Last) (First) (Middle) (Social Security Number)
Address ____________________________________________________________________________________________________

(Number and Street) (Apt No) (City) (State) (Zip Code)


How may we contact you? (Please check all that apply and provide phone number/e-mail address)




Day/Work Phone

( ) ___________________________

May we leave a message? Yes  No 



Evening Phone

( ) ___________________________

May we leave a message? Yes  No 



Cell Phone

( ) ___________________________

May we leave a message? Yes  No 



e-mail




May we leave a message? Yes  No 

Birth Date / / Age Gender Race __ Ethnicity_________ Marital Status

MM DD YYYY (Optional) (Optional)
Preferred Language ________________________________ Do you speak English? Yes  No 

Are you deaf or hard of hearing? Yes  No  Do you need interpreter services? Yes  No 


Have you ever served in the military? Yes  No  Unknown 

Name of Emergency Contact Phone #



Please Include a Release of Information (Last) (First)


Guardianship Information:

Do you have a court appointed legal guardian? Yes  No  If yes, what type?


If yes, please submit a copy of the guardianship decree with this application. The legal guardian must sign the application and all the Authorizations for Releases of information for the application to be processed.
Name of Legal Guardian Relationship

(Last) (First) (Relationship to Applicant)



Guardian’s address (Number and Street) (Apt No) (City) (State) (Zip Code)
How may we contact the guardian? (Please check all that apply and provide phone number/e-mail address)




Day/Work Phone

( ) ___________________________

May we leave a message? Yes  No 



Evening Phone

( ) ___________________________

May we leave a message? Yes  No 



Cell Phone

( ) ___________________________

May we leave a message? Yes  No 



e-mail

_________________________________________________ _ _

May we send a message? Yes  No 




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