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Get the free DMH REFERRAL / EMERGENCY INFORMATION FORM

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LIFESTYLES REFERRAL Please fill out and return to: Kim Irving DMH85 East Newton Street Boston, MA 02118 T: 617.626.8976 F: 6176268794 kimberly.a.irving@mass.gov 1. Client Name: 3. Date of Birth: 5.
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How to fill out dmh referral emergency information

01
Obtain the DMH referral form from the appropriate authority or organization.
02
Fill out the client's personal information, including name, date of birth, address, and contact information.
03
Provide detailed information about the client's emergency situation, including any history of mental health issues or crises.
04
Include any relevant medical information, such as allergies or current medications.
05
Sign and date the form, ensuring that all information is accurate and up to date.

Who needs dmh referral emergency information?

01
Individuals who are experiencing a mental health emergency and require immediate intervention and support.
02
Healthcare providers, social workers, or emergency services personnel who are assisting individuals in crisis situations.
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dmh referral emergency information is a form used to report emergency contact information for individuals receiving services from the Department of Mental Health.
Individuals receiving services from the Department of Mental Health are required to file dmh referral emergency information.
dmh referral emergency information can be filled out by providing emergency contact information and any necessary medical information for the individual receiving services.
The purpose of dmh referral emergency information is to ensure that emergency contacts are readily available in case of a crisis or emergency involving the individual receiving services.
Information such as emergency contacts, medical history, allergies, and any specific instructions in the event of an emergency must be reported on dmh referral emergency information.
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