Request for child/adolescent services effective October 2009



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Commonwealth of Massachusetts Department of Mental Health (DMH)

REQUEST FOR CHILD/ADOLESCENT SERVICES Effective October 2009 (Revised October 2015)


Application for Child/Adolescent Services – Instructions
The Department of Mental Health (DMH) provides services and supports to children and adolescents with serious emotional disturbance and their families to enable them to remain in the community. These services are intended for those youth and their families who need more than an outpatient intervention or medication.
Applications for youth under the age of 18 who request mental health services must include the following completed forms, with parent or legal guardian signatures and dates where indicated:
 Request for Child/Adolescent Services application
 DMH Service Authorization Determination (page 6)
 Authorization(s) for Release of Information
To expedite the determination, DMH encourages applicants to also submit relevant medical and educational information and documents such as:
 Psychiatric assessment completed by a licensed clinician within the previous six months, and/or
 Hospital admission/discharge reports if hospitalized during the previous six months
 Copy of the Individualized Educational Plan (IEP) if one is in place
While submitting medical and educational information at the time of a request for services is not required, it is strongly recommended the information be submitted at the same time. DMH will need to review such information and will require such information at a later date.
If you are a provider of mental health care and making a referral to DMH, please follow the instructions on page two.
Within seven (7) days of receipt of a Request for Child/Adolescent Services application, DMH will contact the parent or other legal guardian by telephone. The purpose of the phone contact will be to:

  • Acknowledge DMH’s receipt of the Request for Child/Adolescent Services application







  • Confirm that the parent or legal guardian wants to continue the determination process




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




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

A DMH Clinical Service Authorization Specialist may request, as necessary, a face-to-face meeting with the applicant and/or guardian to further discuss and assess the needs of the child or adolescent and family.


The DMH Area Director or designee in the Area where services are being sought will make decisions regarding service requests upon receiving and reviewing information in accordance with DMH regulations.
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 (DMH)

REQUEST FOR CHILD/ADOLESCENT SERVICES Effective October 2009 (Revised October 2015)


Application materials are available 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. Applications are available in English. DMH can provide translators for other languages if necessary and provide other assistance as needed.
A completed Request for Child/Adolescent Services application, a signed DMH Service Authorization Determination form (page 5), and Authorization for Release of Information forms must be delivered, mailed or faxed to the DMH Area Office with responsibility for the community where the parent or legal guardian resides at the time of application.
Where to send the application:
Please find your city or town in the list that appears on the following pages and send your application to the respective DMH Office:


Office

Mailing Address

Phone Number

Boston

85 East Newton Street, Boston, MA 02118

(617) 626-9200

Brockton

165 Quincy Street, Brockton, MA 02302

(508) 897-2000

Northampton

1 Prince Street, Northampton, MA 01060

(413) 587-6200

Tewksbury

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

(978) 863-5000

Worcester

361 Plantation Street, Worcester, MA 01605

(774) 420-3140

Applications should NOT be sent to the DMH Central Office at 25 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.
Additional Instructions for Providers of Mental Health Care

A provider of mental health care who makes a referral to DMH must submit relevant clinical information including:


For applicants currently at an inpatient facility
 Psychiatric evaluation, including DSM-IV diagnoses (Axis I-V)
 Any other assessments (e.g. psychosocial, medication, neuropsychological testing, neuropsychological examinations, etc.)
 Hospital Course, including treatment plan
For applicants who currently reside in the community
 Psychiatric evaluation, including DSM-IV diagnoses (Axis I-V)
 Any other assessments (e.g. psychosocial, medication, neuropsychological testing, neuropsychological examinations, etc.)
 Discharge summary, if hospitalized during the previous six months
 Current mental health treatment plan
Providers of mental health care who make a referral to DMH must ensure that signed Authorization for Release of Information forms are included for all clinical information submitted with the request for services. The submission of release forms at the time of application for other documents DMH will need to obtain will facilitate the determination process for the applicant. DMH may also request additional clinical information as necessary.


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