* Required Information
Date of Referral
*
Client Medical Record Number
*
Language Spoken at Home
*
Gender
*
Male
Female
Name of Child
*
Date of Birth
*
Address
*
City
*
Zip Code
*
Phone Number
*
Parent or GUARDIAN (Name and Relation)
*
Reffered By
*
Agency
*
Phone
*
Custody Status
*
Name of School Child Attends
*
INSURANCE INFORMATION
MMIS Number
*
Policy Number
*
Please Select All That Applies
MBHP
MBHP-HNE
BMC/Fallon
Tufts/Network Health
Other
Other
Reason for Referral
**Please remember: IHT is NOT Individual therapy that is provided on an outreach basis! This is intensive family therapy that is provided by a team of a Master’s level clinician and Bachelor’s level support worker. Family must be willing to meet multiple times per week**
Behavioral issues/Symptoms that are being demonstrated in home/at school/in the community
Is youth at risk of being removed from the home (e.g. Hospitalization? DCF placement? Residential?)
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