Massachusetts Behavioral Health Partnership (MBHP) Emergency Service Request Form

If you would rather print out the fact sheet and mail it in, click here to download the PDF version.

Please select the office to which you want to send this form:

ESP requesting services:
Contact:
Phone:
Confirm shifts with:
Phone:	(D) (N)
Contact at service location:
Phone:	(D) (N)
Consumer's name:
Age:	DOB: / /
Consumer's address:

City, state, zip:
Consumer's phone:
Consumer's social security #:	- -
Diagnosis :
DX code:
RX:
Reason for specialing :

Billing Information

Agency :	Massachusetts Behavioral Health Partnership
Authorization #:
No. of units authorized:
Office to bill:
Billing contact:
Address:

City, state, zip:
Phone:
Fax:
Ordering physician :
Phone:
Hospital name:
Phone:
Hospital address:

City, state, zip:
Other information:

Other Consumer Information

Consumer information:
Consumer history: (please include previous placements, pertinent issue, health problems, etc.):
Target behaviors (frequency, patterns, etc.)
TX plan and/or behavior programs
Suggested activities (be specific as possible)
Special skills required
Brief description of service location (setting, type of consumers, rules/guideline, etc.)
Directions to assignment By car: By public transportation:
This form completed by:	Name: Title: Phone: