In Home Behavioral Services (IHBS) Referral Form
Date of Referral:
*
-
Month
-
Day
Year
Date
Client's Legal Name:
*
First Name
Last Name
Client's Affirmed Name:
*
Client's Gender Identity:
*
Man or Boy (CIS)
Woman or Girl (CIS)
Transgender Man or Boy/Trans Man/Masculine
Transgender Woman or Girl/Trans Woman/Feminine
Genderqueer/Gender Expansive/Nonbinary/Neither Exclusively Male nor Female
Client's Date of Birth:
*
-
Month
-
Day
Year
Date
Client's Age (3-21):
*
Client's Primary Language:
*
Client's Preferred Language:
*
Would family be interested in the Multicultural Outreach Team? (Specialty clinical team focusing on multicultural youth and families - current language available is Spanish):
*
Yes
No
Would Family be Interested in the Pride Team (Our inclusive PRIDE Team consists of highly qualified mental health professionals and paraprofessionals who are a part of the LGBTQIA+ community. Our PRIDE Team is thoughtful in our choice of respectful language, behaviors, and continued education to best reflect the current needs and expectations of the LGBTQIA+ community):
*
Yes
No
Insurance ID:
*
Primary Insurance Type (NOTE: Family assistance is not accepted for MassHealth):
*
MassHealth - Beacon
MassHealth - Tufts
MassHealth - MBHP
BCBS
Tufts Health Plan (Commercial)
Beacon (Commercial)
Optum (Harvard Pilgrim)
Optum (United HealthCare)
Optum (UBH)
Other
For Above Enter Other information and/or which BCBS State (i.e. BCBSRI, BCBSMA, etc.):
If able please upload a picture of the front and back of your insurance card
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Guardian's Name:
*
First Name
Last Name
Relationship to Client:
*
Guardian's Phone Number:
*
Please enter a valid phone number.
Guardian's Email:
example@example.com
Guardian's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent(s) Name if Different:
*
DCF Worker:
First Name
Last Name
DCF Phone:
Please enter a valid phone number.
Please Identify if DCF Custody:
CRA
Legal
Referent Name:
*
First Name
Last Name
Referring Agency:
*
Referent Phone:
*
Please enter a valid phone number.
Referent Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If ICC - Have the IHBS Service Units Been Authorized?
Yes
No
Has an IHBS referral been placed to another agency at the same time?
*
Yes
No
If yes, which agencies?
Has the client received IHBS services previously?
*
Yes
No
If yes, which agency?
Please list all Psychiatric Hospitalizations, Crisis Visits, or Risk Assessments that have occurred in the past (1) one year:
*
Risk for Re-Hospitalization (1=Very Low, 3=Moderate, 5=Very Likely):
*
1
2
3
4
5
Other Current Providers (CSA, Psychiatry, Individual Therapist, Etc.): Please Include Name, Service, Agency and Phone Number
*
Reason for Referral/Goals (Symptoms, Behavioral/Social/Emotional Functioning of Youth/Family, Focus of Treatment):
*
Medications (include Name, Dose, Frequency and Indication):
*
Family's Preference for Scheduling (include days and times):
*
ICC Name:
First Name
Last Name
ICC Phone:
Please enter a valid phone number.
ICC Agency:
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IHT Name:
First Name
Last Name
IHT Phone:
Please enter a valid phone number.
IHT Agency:
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Outpatient Name:
First Name
Last Name
Outpatient Phone:
Please enter a valid phone number.
Outpatient Agency:
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Please identify one or more of these skill building categories to be included on the updated treatment plan/care plan with descriptive goals that include IHBS interventions:
*
Physically Aggressive Behavior
Verbally Aggressive Behavior
Non-Compliance
School Refusal
Tantrums
Behavior Management Skills
Self-Management Skills
At-Risk Factors or Safety Concerns Present (Please Choose All that Apply):
*
Suicidal Ideations
Suicidal Gestures
Self-Injurious Behavior
Homicidal Ideations
Current Substance Use
History of Substance Use
Runs Away
Violence/Aggression Towards Others
Takes Dangerous Risks
School Refusal
Lack of Social Group
Gang Involvement
Isolation
Med Compliance Issues
Fire Setting
High Risk Sexual Activity
Sexualized Aggression and/or behaviors
Trauma History (please explain below)
Medical/Physical Issues (please explain below)
None
Explain Trauma History and Medical Physical Issues:
Safety Concerns for Home-Based Team to Plan FOR (please choose all that apply):
*
Unsafe Neighborhood
Current Domestic Violence
Violent Family Member or Person Involved with Family
Lack of Safe Parking Available
Animals (Please list below for Allergies)
Suspected Illegal Substances in Home
Weapons in Home
None
Describe the Safety Concerns for Home-Based Team to Plan For:
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If you have any questions call (774) 206-1125 or our referral line directly at (978) 409-5855.
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