Mental Health Referral Request

Mental Health Referral Request

Lexington Human Services Department
There are two primary ways to contact the Human Services department with regard to a mental health referral
1. For fastest service, fill out the online form below.
2. Call the Lexington Community Center front desk at (781) 698-4840
Once the form is submitted, please expect to hear from a Human Services staff member within 3-5 business days. Staff will respond to inquiries during business hours only.

Human Services Office Hours: 8:30AM - 4:30PM Monday-Friday

This program is intended for residents of Lexington, MA

For life-threatening mental health emergencies, call 911 or go directly to the nearest emergency room.

If you or someone you know is experiencing suicidal thoughts or emotional distress, dial 988, the National Suicide and Crisis Lifeline. The 988 Lifeline provides free and confidential emotional support 24/7 through a network of local centers across the United States. You can reach the Lifeline by calling or texting 988.

For urgent mental health or emotional needs that are not immediately life-threatening, call Advocates Adult & Youth Mobile Intervention (MCI) at (800) 540-5806 to speak with a clinician. The MCI team is available 24 hours a day, 7 days a week, and can respond in homes, schools, or other community settings.
Check this box if you making this referral on behalf of someone else
Requester Information
Relationship to client
Full Name

First NameLast Name
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Client Information
Full Name

First NameLast Name
Date of birth

MonthDayYear
Gender identity
Preferred pronouns
Preferred language
Parent/legal guardian's name (if client is under 18)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary phone number
Please enter a valid phone number.Format: (000) 000-0000.
Other phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Preferred method of contact
Request for Support Request
Please provide a brief description of presenting issues
Any additional information we should know

- I understand that a referral for mental health services may be conducted by Human Services Department staff to help connect me to the appropriate supports. Documentation may be required to verify the information I provide. I understand that services are limited, that completing this form is not a guarantee of service eligibility, and that the Human Services Department will determine the best pathway for referral.
- I authorize the Human Services Department to share information relevant to my situation interdepartmentally within the Town, as well as with designated mental health providers or referral partners, solely to connect me to needed care and support. I understand that my identity will be protected to the greatest extent possible and that any information shared will be limited to what is necessary to make the referral.
- I further authorize the Human Services Department to communicate directly with the receiving provider, agency, or other appropriate Town department, as needed, to facilitate access to services.
- I certify that all information provided in this form is true and accurate to the best of my knowledge.
Signature

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For life-threatening mental health emergencies, call 911 or go directly to the nearest emergency room.

If you or someone you know is experiencing suicidal thoughts or emotional distress, dial 988, the National Suicide and Crisis Lifeline. The 988 Lifeline provides free and confidential emotional support 24/7 through a network of local centers across the United States. You can reach the Lifeline by calling or texting 988.

For urgent mental health or emotional needs that are not immediately life-threatening, call Advocates Adult & Youth Mobile Intervention (MCI) at (800) 540-5806 to speak with a clinician. The MCI team is available 24 hours a day, 7 days a week, and can respond in homes, schools, or other community settings.
Should be Empty:

Mental Health Referral Request

Requester Information

Client Information

Request for Support Request