Referrals and Intake

Make a Referral

We serve Greater Boston and surrounding areas. We offer flexible appointment hours including weekdays, evenings and Saturdays.

Please fill out the form below with the required information to initiate a referral or intake procedure.

Referrals/Intake Form

Referrals/Intake Form

Please fill out all fields.

First and Last
First and Last
Optional
First and Last
What are the behavioral concerns, community support needs, mental health needs, or services needed for individual or family?

LCHI

You may choose more than one.
Please download, fill out and upload the forms below with your referral.
LCHI Notification of Treatment
LCHI Clinic Acknowledgment of Receipt
LCHI Clinic Authorization for Release of Information
LCHI Complain Policy and Procedures
LCHI Off-Hours Emergency Policy
LCHI Clinic PCP Tool
LCHI Recovery Consent 42 CFR Part 2 and HIPAA
CANS CONSENT FORMS
CANS English
CANS Spanish
CANS Vietnamese
CANS Russian
CANS Brazilian Portuguese
CANS Haitian Creole

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