Intensive Home-Based Therapy Referral Form

Intensive Home-Based Therapy (IHBT) Services

Client Referral Form
Referral Source Contact Name*

First NameLast Name
Referral Agency
Doctor's office, county department, etc.
Referral's Contact Email*
example@example.com
Are you referring for yourself or on behalf of someone else?*

MyselfMy child/youthSomeone Else
Name of person seeking services*

First NameLast Name
Date of Birth*

MonthDayYear
Date
If you are referring on behalf of a youth, what is their Parent or Caregiver's name and relation?

First NameLast NameRelationship
Your email or the Caregiver's Email*
example@example.com
Your Phone Number or Caregiver's Phone Number*

Area CodePhone Number
Address of person seeking services*

Street Address

Street Address 2

CityState

Zip Code
What is the person's County of Residence?*
What is the insurance name of the person being referred*
Example: Aetna, Medicaid, Cigna, etc.
What concerns are you hoping to address with services?*
How did you hear about NYAP?*

Social MediaGoogle SearchWebsiteParticipant of other NYAP program(s)Friend ReferralDrive byOther
Please verify that you are human*
Click Submit Below to Complete

Once completed, your referral will be processed by the NYAP office nearest you. Most referrals will be processed and contacted within 2 BUSINESS DAYS.
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Intensive Home-Based Therapy (IHBT) Services