Referral Form printable pdf download

UMASS FAMILY COURT CLINIC

Department of Psychiatry, University of Massachusetts Medical School

REFERRAL FORM

The UMass Family Court Clinic provides brief, focused evaluations of urgent family matters presenting to Worcester Probate

and Family Court judges. Urgent, but clearly circumscribed family disputes are most amenable to brief evaluations. Due to

the brief nature of the assessments, recommendations are generally centered on the short term needs of the family. A written

report of the evaluation is sent to the Court within the time frame determined by the urgency of the issues. Emergency

request for evaluations are handled as quickly as possible. To expedite an urgent request, please contact the clinic secretary

or _________________ (see below

Person Completing Form: ______________________________________________________ Phone: ____________________

Date of Court Order: _________________________

Referring Judge: _____________________________________________

Case Name: ___________________________________ Docket #: _________________ Return Court Date: ______________

PLAINTIFF

Name: ______________________________________ Phone (home): __________ (work): ____________ (cell): ___________

Address: ________________________________________________________________________________________________

Attorney Name/Address: _______________________________________________________ Phone: ____________________

DEFENDANT

Name: ______________________________________ Phone (home): __________ (work): ____________ (cell): ___________

Address: ________________________________________________________________________________________________

Attorney Name/Address: _______________________________________________________ Phone: ____________________

CHILDREN

Name: ____________________________ Age: ____

Name: _______________________________ Age: ____

Name: ____________________________ Age: ____

Name: _______________________________ Age: ____

Legal proceeding before the Court (please specify): ____________________________________________________________

_________________________________________________________________________________________________________

Any Current 209A: Yes ____ No ____

Children on 209A: Yes ____ No ____

Any Noncurrent 209A: Yes ____ No ___

Present Custody Status: Sole legal_______________

Joint Legal________________

The Court's reason for referral for Brief Psychological Evaluation (Please check or circle all that apply).

•

Interparental: a) conflict _____

b) violence_____

•

Mental status of: a) mother _____ b) father

_____

•

Substance abuse: a) mother _____

b) father

_____

•

Disputed visitation/access: _____

Current adjustment of child(ren): _____

•

Safety of child(ren) with parent(s): _____ (Please specify parent): ____________________________

•

Question of: a) emotional abuse _____

b) physical abuse _____

c) sexual abuse _____

d) neglect ______

•

Ability of parent to provide adequate care for child: _____

(please specify parent): __________________

Please state the focus of the assessment: ____________________________________________________________________

________________________________________________________________________________________________________

Please call or fax in this information to ____________ at the Department of Psychiatry, UMMS, XXX-XXX-XXXX and FAX Court

order to XXX-XXX-XXXX. Please contact ________________ at XXX-XXX-XXXX for further information.

Rev. 9/3/08

Form 1B

Referral Form

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