Professional Mental Health Referral Checklist

How to use this worksheet

Begin with the practical steps on the MVBH start page for prospective participants, then use the admissions information and screening guidance to plan your questions. Complete only the items you can answer without guessing. Mark unknown items for discussion rather than treating this worksheet as an assessment, referral approval, or admission decision.

Use one copy for each person or referral. Add the date and identify whether the answers came from the adult, a family member, a clinician, or another referrer. Keep the worksheet in a private location if you add personal information.

1. Write down the reason for contacting MVBH in one general sentence.
2. List practical questions about program format, attendance, location, and virtual participation.
3. Mark clinical, benefits, privacy, and records questions for the appropriate conversation.
4. Note who will ask each question and how the answer will be confirmed.

This checklist supports preparation. It cannot diagnose someone, choose treatment, change medications, or establish the right level of care. A screening or appropriate clinical assessment determines fit.

Questions about schedule and daily responsibilities

Review the formats described on the MVBH adult treatment programs page, then separate scheduling questions from the coverage questions on the benefits verification page. A workable schedule does not confirm clinical fit, coverage, authorization, availability, or a start date. Ask about each issue separately and record who provided the answer.

List obligations that could affect regular participation without adding private health details. Useful topics include work, school, caregiving, transportation, access to a private space for virtual sessions, and other fixed commitments. Ask which program formats may be discussed during screening.

For in-person care, confirm that the adult can attend at 77 Elm St, Amesbury, MA 01913. Adults from New Hampshire, Vermont, Maine, Rhode Island, and Connecticut may travel to Amesbury for care. MVBH does not operate facilities in those states.

For Virtual IOP, ask whether the person can be physically present in Massachusetts during every live session. Keep diagnosis, medication information, member ID, trauma history, substance-use history, and similar sensitive details out of a general website form. Share them only through an appropriate process requested by staff.

Questions about MVBH scope and next steps

Use the MVBH contact page for practical next steps, but use the crisis resources page for urgent safety support. MVBH is an adult outpatient provider, not a hospital, residential program, overnight setting, emergency service, or onsite detox facility. A direct conversation is needed when the appropriate setting or service remains uncertain.

Before making contact, confirm which question you need answered first: service scope, screening, location, virtual eligibility, benefits verification, records transfer, or another practical issue. This helps staff direct the inquiry without collecting unnecessary information in a public form.

For in-person services, the only MVBH location is 77 Elm St, Amesbury, MA 01913. Virtual IOP participants must be physically present in Massachusetts for every live session. Location eligibility does not establish clinical fit, coverage, availability, or admission.

Call MVBH at 978-233-9597 for the appropriate next step. Have this checklist available, but begin with general questions. Ask staff how sensitive clinical, benefits, or records information should be shared before providing it.