In Home Behavioral Services (IHBS) Referral Form

In Home Behavioral Services (IHBS) Referral Form
*Please note that you will not qualify for IHBS if already enrolled in Applied Behavior Analysis (ABA) services.
Date of Referral:*

MonthDayYear
Date
Client's Legal Name:*

First NameLast Name
Client's Affirmed Name:*
Client's Gender Identity:*

Man or Boy (CIS)Woman or Girl (CIS)Transgender Man or Boy/Trans Man/MasculineTransgender Woman or Girl/Trans Woman/FeminineGenderqueer/Gender Expansive/Nonbinary/Neither Exclusively Male nor Female
Client's Date of Birth:*

MonthDayYear
Date
Client's Age (3-21):*
Client's Primary Language:*
Client's Preferred Language:*
If the primary language is not English, would the family be interested in utilizing an interpreter for services?*

YesNoN/A
Would family be interested in the Multicultural Outreach Team? (Specialty clinical team focusing on multicultural youth and families - current language available is Spanish):*

YesNo
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):*

YesNo
Insurance ID:*
Primary Insurance Type (NOTE: Family assistance is not accepted for MassHealth):*

MassHealth - BeaconMassHealth - TuftsMassHealth - MBHPBCBSTufts 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 NameLast 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

CityState / Province

Postal / Zip Code
Parent(s) Name if Different:*
DCF Worker:

First NameLast Name
DCF Phone:
Please enter a valid phone number.
Please Identify if DCF Custody:

CRALegal
Referent Name:*

First NameLast Name
Referring Agency:*
Referent Phone:*
Please enter a valid phone number.
Referent Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If ICC - Have the IHBS Service Units Been Authorized?

YesNo
Has an IHBS referral been placed to another agency at the same time?*

YesNo
If yes, which agencies?
Has the client received IHBS services previously?*

YesNo
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):*

12345
Other Current Providers (CSA, Psychiatry, Individual Therapist, Etc.): Please Include Name, Service, Agency and Phone Number*
Reason for Referral/Goals: Please provide a brief description (2-3 sentences) of the 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 NameLast Name
ICC Phone:
Please enter a valid phone number.
ICC Agency:
File Upload

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IHT Name:

First NameLast Name
IHT Phone:
Please enter a valid phone number.
IHT Agency:
File Upload

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Outpatient Name:

First NameLast Name
Outpatient Phone:
Please enter a valid phone number.
Outpatient Agency:
File Upload

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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 BehaviorVerbally Aggressive BehaviorNon-ComplianceSchool RefusalTantrumsBehavior Management SkillsSelf-Management Skills
At-Risk Factors or Safety Concerns Present (Please Choose All that Apply):*

Suicidal IdeationsSuicidal GesturesSelf-Injurious BehaviorHomicidal IdeationsCurrent Substance UseHistory of Substance UseRuns AwayViolence/Aggression Towards OthersTakes Dangerous RisksSchool RefusalLack of Social GroupGang InvolvementIsolationMed Compliance IssuesFire SettingHigh Risk Sexual ActivitySexualized Aggression and/or behaviorsTrauma 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 NeighborhoodCurrent Domestic ViolenceViolent Family Member or Person Involved with FamilyLack of Safe Parking AvailableAnimals (Please list below for Allergies)Suspected Illegal Substances in HomeWeapons in HomeNone
Describe the Safety Concerns for Home-Based Team to Plan For:
What Animals Are in the Home?
File Upload

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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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