IHBS Referral Form

IHBS REFERRAL FORM

ALLY BEHAVIORAL HEALTH
Child's Legal Name: *

First Name Last Name
Child's preferred name:
Child's DOB *

Month Day Year
Date
Child's gender at birth *
Child's identified gender *
Referral Information
IHBS Referral completed by *

First Name Last Name
Is this referral from a parent/guardian or a provider/agency? *
Agency Name *
Relationship to child *
Phone Number *

Area Code Phone Number
Email *
example@example.com
Preferred contact *
Comments
For this referral, is/are the guardian(s) interested in any available IHBS provider or are they seeking this specific agency's services? *
Our agency will assist in coordinating services if you are interested in a first available provider in the area.
Any requests/ accommodations for IHBS Services?
ex. Specific therapist request, language needs, etc.
Child Information
Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Child's Phone Number (optional)

Area Code Phone Number
Fluent Language(s) in the home *
Who does the child live with (please include all household members for all relevant households). *
Current State Agency Involvement? *
Ex. DCF, DDS, DHM - Please list all applicable contacts
Child's Insurance Information
Insurance Carrier *
ex Tufts, MBHP, Beacon
Member ID *
Located on front of insurance card
Subscriber Name *
Who is the policy holder (parent, etc)?
Upload a copy of the front of your insurance card

Browse Files

Cancel of
Upload a copy of the back of your insurance card

Browse Files

Cancel of
Is there a secondary insurance? *
Secondary Insurance *
Secondary Insurance Member ID *
Located on front of insurance card
Secondary Insurance Subscriber Name *
Who is the policy holder (parent, etc)?
Upload a copy of the front of your insurance card

Browse Files

Cancel of
Upload a copy of the back of your insurance card

Browse Files

Cancel of
Parent/Guardian Information
Parent/Legal Guardian Name *
Parent/Legal Guardian Phone Number *

Area Code Phone Number
Parent/Guardian Email *
example@example.com
Same address as child? *

Yes No, alternate address
Parent/Guardian Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add an additional parent/guardian? *
Parent/Legal Guardian Name *
Same address as child? *

Yes No, alternate address
Parent/Guardian Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Legal Guardian Phone Number *

Area Code Phone Number
Parent/Guardian Email *
example@example.com
Child's Behaviors

Present and historical behavioral concerns
A presence or history of... *

Physical Aggression Verbal Aggression Object Aggression Swearing Disruptive Behavior Stealing Fire Setting School Truancy Inappropriate Sexual Behavior Cruelty - Animals Running away Oppositional/Defiant Drug/Alcohol use
Why are in-home behavioral supports being sought at this time? Please provide a brief statement. *
Medical History
Allergies: *
Current Medications: *
Please list all medications and current doses
Medical History: *
Mental Health Services History (please list any former/current providers, hospitalizations, inpatient/CBAT support, etc) *
Please note any past/current psychiatric diagnoses *
Please upload any additional information that may be useful for our clinical team (optional)

Browse Files
Ex. Medical reports, IEPs, Evaluations, etc Cancel of
By submitting this form, I hereby authorize Ally Behavioral Health to use this information provided to verify eligibility for the requested service through the insurance information provided. Information shared will also be used to authorize the requested services, as allowed by your insurance carrier(s).

If submitting this form on behalf of a family, please include a signed release of information form demonstrating you have recieved the family's consent to share this information (referrals will not be processed without this).
Should be Empty:

IHBS REFERRAL FORM

Referral Information

Child Information

Child's Insurance Information

Parent/Guardian Information

Child's Behaviors

Medical History