Eliot CSA Referral Form

Supporting youth in reaching their life goals

Youth being referred must meet the following eligibility criteria:

Currently on or eligible for Mass Health.

Under the age of 21;

Functionally Impaired (SED)

Have a parent/guardian able to provide consent and participate in the care planning process

Youth Information (please provide all requested information to the best of your knowledge.)

Youth's First Name Last Name   Sex Male Female

Address City Zip code   Age

Primary Language   Child's Mass Health VerifiedYes No

Parent/Guardian Information

Child Lives with Mother Father Both OtherPlease specify

Parent/Guardian Name

Relationship to child Check if legal guardian Address Home Phone Other Phone Primary Language

Referral Source(If not parent/guardian)

Referring agency or School Representative's name   Name of Agency or School