Community Health Institute


We serve Boston, Southeast Region and Surrounding Areas

Please fill out the form below with the required information.

For urgent referrals, please call the clinic directly (781) 885-7252 and ask to speak to our referral coordinator.

We offer flexible appointment hours including weekdays, evenings and Saturdays.


Referrals-Intake Form

*Red indicates a required field


Contract Person Name:

Contract Person Phone Number:

Contract Person Email Address:

Patient’s Name:

Patient's Date of Birth:

Parent/Guardian Name:

Patient’s Address:

Patient's Best Phone:

Patient's Other Phone: (optional)

Your Program Choice(s):
You may choose more than one program.

What Kind of Referral:

What Kind of Payment:

Why is patient being referred?
What are the behavioral concerns, community support needs, mental health needs, or services needed for individual or family?


*Red indicates a required field

Important downloadable forms:

Info that needs to be faxed with referrals:
Fax: (781) 885-7256