Admissions/Intake Dept: 508-427-5362
Main Number: 508-521-2200

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Request Services

Use this page to request services by either selecting the Initial Referral Form or the Application for ABA Services Form below.

Select Your Preference:

Outpatient Mental Health/CBHI Services

Request for MH/CBHI Services

Client Contact Information

Services Requested
Outpatient: Individual, couples and Family therapy: Therapy provided by a therapist to address Behavioral l health and substance use needs (age 3 years old and above) typically weekly/biweekly.CBHI in Home Therapy (IHT)IHT: Intensive home based treatment provided by a therapeutic team to support youth and family with managing symptoms, communication, and healthy functioning (under 21 years old) typically more than 1x week)CBHI Therapeutic Mentor (TM)TM: One to one mentoring between a youth and a trained mentor to focus on skill building and healthy living within the home and community (under 21years old)CBHI in Home Behavioral Services (IHBS)IHBS: Home based treatment provided by a team to youth and family to implement a highly specific behavior management plan with interventions designed to address specific behaviors related to the youth's behavioral health needs (under 21years old) typically more than 1x week)Group TherapySubstance Abuse Evaluation

Enter information for client to be referred for services.

First Name *

Middle Name

Last Name *

Gender

MaleFemale

Race

Ethnicity

Date of Birth

Month *

Day *

Year *

Client Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Primary Phone *Example: (999) 999-9999

Primary Phone Type *

MobileHomeWork

Alternate Phone Example: (999) 999-9999

Alternate Phone Type

MobileHomeWork

Consumer/Parent Email Address

Language(s) Spoken by Client *

Language(s) Spoken by Parent(s)/Guardian

If Adult, Who to Contact in Case of Emergency?

If Adult, Emergency Contact Number

Parent/Guardian Information

Parent/Guardian 1 Contact Name
Parent/Guardian 1 Contact Number

Parent/Guardian 2 Contact Name
Parent/Guardian 2 Contact Number
Who Has Custody of the Child?
Relationship to Consumer
Any Children Under the Age of 3
Name of School the Child Attends

Name of Person Referring

Referral Source First Name *
Referral Source Last Name *
Referred By (Agency Name)
Referral Source Phone Number *Example: (999) 999-9999
Referral Source Phone Number Extension Example: x999
Person Filling Out the Form

Service Request Information

Is Client Currently on Meds
YesNo
Name of Prescriber and #
Any previous EI Services if child under 3
Is DCF Involved
YesNo
If Yes, DCF Name and #
Court / Probation Involvement or Incarceration History?
Any CSA Involvement OR Community Providers

Client Environment Information

Any Present Domestic Violence in Home *
YesNo
Any Present Suicidal or Homicidal Ideation *
Yes (Suicidal)Yes (Homicidal)No
Any Present Aggressive Behaviors *
YesNo
Any Current Substance Use *
YesNo
REASON FOR REFERRAL *
Do You Need Assistance With (Check All That Apply):
VisionMobilityHearing

Insurance Information

Name of Insurance Company *
Policy #
Subscriber Name
Subscriber DOB
Group #

Verification

Please enter any two digits *Example: 12
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Early Intervention (MA 0-3)

Request for EI Services
(MA 0-3)

Child Contact Information

Enter information for child to be referred for services.

First Name *

Middle Name

Last Name *

Gender

MaleFemale

Race

Ethnicity

Date of Birth

Month *

Day *

Year *

Child Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Primary Phone *Example: (999) 999-9999

Primary Phone Type *

MobileHomeWork

Alternate Phone Example: (999) 999-9999

Alternate Phone Type

MobileHomeWork

Consumer/Parent Email Address

Language(s) Spoken by Child *

Language(s) Spoken by Parent(s)/Guardian

Parent/Guardian Information

Parent/Guardian 1 Contact Name
Parent/Guardian 1 Contact Number

Parent/Guardian 2 Contact Name
Parent/Guardian 2 Contact Number

Who Has Custody of Child
Relationship to Consumer
Any Other Children Under the Age of 3
Name of Childcare the Child Attends

Name of Person Referring

Referral Source First Name *
Referral Source Last Name *
Referred By (Agency Name)
Referral Source Phone Number *Example: (999) 999-9999
Referral Source Phone Number Extension Example: x999
Person Filling Out the Form

Service Request Information

Is Child Currently on Meds
YesNo
Name of Prescriber and #
Any previous EI Services if child under 3
Is DCF Involved
YesNo
If Yes, DCF Name and #
Court / Probation Involvement or Incarceration History?
Any CSA Involvement OR Community Providers

Child Environment Information

Any Present Domestic Violence in Home *
YesNo
Any Present Suicidal or Homicidal Ideation *
Yes (Suicidal)Yes (Homicidal)No
Any Present Aggressive Behaviors *
YesNo
Any Current Substance Use *
YesNo
REASON FOR REFERRAL *
Do You Need Assistance With (Check All That Apply):
VisionMobilityHearing

Insurance Information

Name of Insurance Company *
Policy #
Subscriber Name
Suscriber DOB
Group #

Verification

Please enter any two digits *Example: 12
This box is for spam protection - please leave it blank:

Birth to Three Services (CT)

Request for Birth to Three Services
(CT)

Autism Services (ABA Over 3 MA & CT)

Request for Autism Services
(ABA Over 3 – MA & CT)

Child Contact Information

Enter information for child to be referred for services.

First Name *
Middle Name
Last Name *
Gender
MaleFemale
Race
Ethnicity

Date of Birth

Month *

Day *

Year *

Child Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Primary Phone *Example: (999) 999-9999
Primary Phone Type *
MobileHomeWork
Alternate Phone Example: (999) 999-9999
Alternate Phone Type
MobileHomeWork
Consumer/Parent Email Address
Language(s) Spoken by Child *
Language(s) Spoken by Parent(s)/Guardian

Parent/Guardian Information

Parent/Guardian 1 Contact Name
Parent/Guardian 1 Contact Number

Parent/Guardian 2 Contact Name
Parent/Guardian 2 Contact Number

Who Has Custody of Child
Relationship to Consumer
Any Other Children Under the Age of 3
Name of Childcare the Child Attends

Name of Person Referring

Referral Source First Name *
Referral Source Last Name *
Referred By (Agency Name)
Referral Source Phone Number *Example: (999) 999-9999
Referral Source Phone Extension Example: x999
Person Filling Out the Form

Service Request Information

Services Requested *
Autism Services (ABA - Over 3 CT)Autism Services (ABA - Over 3 MA)
Is Child Currently on Meds
YesNo
Name of Prescriber and #
Any previous EI Services if child under 3
Is DCF Involved
YesNo
If Yes, DCF Name and #
Court / Probation Involvement or Incarceration History?
Any CSA Involvement OR Community Providers

Child Environment Information

Any Present Domestic Violence in Home *
YesNo
Any Present Suicidal or Homicidal Ideation *
Yes (Suicidal)Yes (Homicidal)No
Any Present Aggressive Behaviors *
YesNo
Any Current Substance Use *
YesNo
REASON FOR REFERRAL *
Do You Need Assistance With (Check All That Apply):
VisionMobileHearing

Insurance Information

Name of Insurance Company *
Policy #
Subscriber Name
Subscriber DOB
Group #

Verification

Please enter any two digits *Example: 12
This box is for spam protection - please leave it blank:

To request services, please fill out the form on this page or call:
Intake/Admissions Dept: 508-427-5362

For employment inquiries, please fill out the form on our Careers page.

Below is the mailing address for South Bay Community Services’ administrative office, including Accounting, Billing, Payroll, Human Resources and Intake departments.

South Bay Community Services
1115 West Chestnut Street
Brockton, MA 02301

To file a formal complaint, please call our Compliance Hotline at 508-521-2850.

South Bay News and Headlines

South Bay Community Services Receives Workforce Training Grant

…

Behavioral Health Organization Announces Rebrand to South Bay Community Services

…

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CARF Accreditation

Commission on Accreditation of Rehabilitation Facilities is one of the premier accreditation services in the mental health industry. Achieving accreditation requires a service provider to commit to quality improvement, focus on the unique needs of each person the provider serves, and monitor the results of services.

Proud Member of the Association for Behavioral Healthcare

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