• Children's Behavioral Health Initiative (CBHI) Referral Form

  • Referral Form

    Page 1 of 2
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  • B. Enter Youth/Client Information

  •  - -
  • C. Enter Parent/Caregiver Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • D. Enter Referral Information

    If referral source is not parent/caregiver
  • Format: (000) 000-0000.
  • E. Enter Insurance and Medical Information

  • F. Specify Reason for Referral

  • Service Request (Selection made in Question A)

    Page 2 of 2
  • Therapeutic Mentoring (TM) pairs a youth with an adult mentor to help the youth build and improve their social, communication, and life needs.

    -Typical Frequency: Weekly sessions at home or in the community
    -Who can Benefit: Youth who have moderate to severe behavioral health symptoms and who need support in the areas of problem-solving, social skills, communication, or conflict resolution. To receive TM, the youth also needs to be receiving another behavioral health service (outpatient, IHT, IHBS, ICC, or FIT)

  • In-Home Therapy (IHT) is intensive family therapy provided by a team of two behavioral health staff to help youth with social, emotional, or behavioral challenges.

    -Typical Frequency: 1-3 sessions per week that occur at home or in the community
    -Who can Benefit: Families of youth with moderate to severe behavioral health symptoms who want to help resolve conflicts, learn new ways to talk to and understand each other, create new helpful routines, and find community resources

  • In-Home Behavioral Services (IHBS) is behaviorally based therapy provided by a two-person behavioral health team that works directly both with the youth and the caregiver. Together, they develop a targeted behavior plan that the caregiver and youth can implement at home.

    -Typical Frequency: 1-3 sessions per week that occur at home or in the community
    -Who can Benefit: Youth whose behaviors are significant enough to interfere with their functioning at home or in the community

  • For Therapeutic Mentoring:

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