IIHS Referral Form

Ohio IIHS Referral Form
Please complete all sections below:
Your name*

First NameLast Name
Relationship to the youth*
Your phone #*
Today's date

MonthDayYear
YOUTH INFORMATION
Youth's name*

First NameLast Name
Gender*

MaleFemaleNonbinaryOther
Birth date*

MonthDayYear
Age
County?*
Reason for referral or any other relevant background information*
Previous or current diagnoses
Current medications
PARENT/GUARDIAN CONTACT INFORMATION
Name*

First NameLast Name
Phone #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: