Make A Families Matter of RI Referral

Counseling/Evaluations

To begin the referral process, please complete the form below. If you need assistance, please call our referral line at 401-471-4935 (English) or 401-471-3997 (Español). Our intake coordinator will return your call within 48 hours.

  • Neighborhood Health Plan of Rhode Island
  • United Behavioral Health
  • DCYF 005 Provider
  • Blue Cross/Blue Shield RI
  • Self Pay
  • Tufts Health Plan

Instructions: All fields are required unless otherwise noted as optional. If you have more than one client name you will have the opportunity to fill out additional forms once this form is submitted. Please be sure to include name, date of birth and insurance information for each child.

Families Matter of RI Referral Form - Counseling/Evaluations
This form is for mental health counseling and evaluations.

Referral Information

Client Information

Parent Information

Parent 2 Information (Optional)

DCYF

Foster Care Information

Primary Insurance Information

Secondary Insurance Information

Appointment Information

Other Information (Optional)

Office Only