In-Home Therapy (IHT) Referral Form
Program designed to provide high-level behavioral health services to children and families in order to improve wellness and prevent the need for other more restrictive levels of care. Clinical teams work with families in their homes at least two times per week. Please contact CBHI Referral Specialist at 978-409-5855 with any questions.
Date of Referral:
*
-
Month
-
Day
Year
Date
Client's Legal Name:
*
First Name
Last Name
Client's Affirmed Name:
*
Include N/A if not applicable for client.
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:
*
Family's Preferred Language:
*
Language(s) family prefers clinician to speak
If the primary language is not English, would the family be interested in utilizing an interpreter for services?
*
Yes
No
N/A
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
Other Languages Spoken:
*
Primary Insurance Type (select insurance):
*
MassHealth - Wellsense
MassHealth - Tufts
MassHealth - MBHP
BCBS
Tufts (Commercial)
Beacon (Commerical)
Optum (Harvard Pilgrim)
Optum (United HealthCare)
Optum (UBH)
Other
Insurance ID:
*
If MassHealth: include number that starts with 100/1000
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:
*
Parent Name (if different):
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Guardian's Email:
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Members of Household:
*
DCF Worker:
First Name
Last Name
DCF Worker Phone Number:
Please enter a valid phone number.
Please Identify if DCF custody is:
CRA
Legal
Referent Name:
*
First Name
Last Name
Referring Agency:
*
Type of Referring Agency:
*
Mobile Crisis
Inpatient/24hr level of care
Other
Referent Phone Number:
*
Please enter a valid phone number.
Referent Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If ICC - Have the IHT service units been authorized?
Yes
No
Has an IHT referral been placed to other agencies?
*
Yes
No
If Yes, Which Agencies:
Has the family received IHT services previously?
*
Yes
No
If Yes, Which Agency? When? Reason for Termination:
Family's Preference for Scheduling (include days and times):
*
Have you spoken to the family about this referral?
*
Yes
No
Has the family voluntarily agreed to this referral?
*
Yes
No
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 list Name, Service, Agency & 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. Please also include information regarding reasons this family/client would benefit from working with our Pride team):
*
Reason IHT Level of Care needed (please choose all that apply):
*
Outpatient services alone are not sufficient to meet youth and family's needs for clinical intervention
Need for increased frequency/duration/flexibility of family sessions depending on need in the home and community
Need for 24/7 urgent telephonic response and risk management/safety planning
Youth at risk for out-of-home placement
Need for care coordination with school, other providers, state agencies, natural supports, etc.
Need treatment to enhance youth's problem-solving, limit setting, and communication to sustain youth in home
Strengthen caregiver(s) ability to sustain youth in home
Client's At-Risk Factors Present (please choose all that apply):
*
Suicidal Ideations
Suicidal Gestures
Self-Injurious Behavior (cutting, burning, etc.)
Homicidal Ideations
Current Substance Use
History of Substance Abuse
Running Away
Violence/Aggression towards others
Lack of Social Group
Isolates
School Refusal
Gang Involvement
Sexualized Aggression/Behavior
Sexual Promiscuity
Takes Dangerous Risks
Fire-Setting
Not Medication Compliant
Medical/Physical (please explain below)
Trauma History (please explain below)
Other (please explain below)
Explain Client's Medical/Physical Issues, Trauma History or Other At-Risk Factors Present:
Caregiver At-Risk Factors Present (please choose all that apply):
*
Current Substance Use
History of Substance Use
Not Medication Compliant
Housing Instability
Financial Distress
Current Domestic Violence
History of Domestic Violence
Unable/Unwilling to Provide Adequate Supervision
Lack of Natural Supports
Mental Health Diagnoses - In Treatment? (please explain below)
Medical/Physical Issues (please explain below)
Other (please explain below)
None
Explain Caregiver Mental Health Diagnoses (include if in treatment), Medical/Physical Issues or Other At-Risk Factors Present:
Identify which Caregiver the At-Risk Factors apply to:
Safety Concerns for Home-Based Clinician to Plan For:
*
Unsafe Neighborhood
Current Domestic Violence
Violent Family Member or Person Involved with Family (please describe below)
Lack of Safe Parking Available
Animals
Suspected Illegal Substances in Home
Weapons in Home
None
Provide details on Violent Family Member or Person Involved Involved with Family:
What Animals Are in the Home?
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