Mental Health Access and Juvenile Justice Diversion

Please submit this referral form if you are interested in completing the Massachusetts Youth Screening Instrument (MAYSI-2) or the Pediatric Symptom Checklist (PSC).


Crisis services are available 24 / 7 - 365:

Common Ground at 800-231-1127 and New Oakland at 877-800-1650


Individual's Information

If DOB is not available, please type "unknown"

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Parent / Guardian's Information

Phone

Referral Source's Contact Information

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School's Information

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Please attach "Consent for Participation" and "Consent and Authorization to Release Protected Health Information"

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