IHTS REFERRAL FORM

All information submitted on this referral form is completely confidential, secure and encrypted. After you submit the referral form, you will be emailed a copy for you records.

PLEASE NOTE: This referral form is only for professional providers looking to refer qualifying individuals to our IHTS program. If you are a parent, please use our Self-Referral form. In order to qualify for in-home therapy services, traditional office-based outpatient treatment services were previously attempted, but were found to be inappropriate or not effective. There is also a need for linkage and/or coordination with other service systems. Appropriate referrals are for individuals with complex clinical needs that traditional outpatient services cannot adequately address.

For specific questions about entrance criteria, please call Samantha Dunn @ 336-899-8800 ext. 17.

CLIENT INFORMATION

First Name

Last Name

Birthday

Please Explain

Gender

Male
Female
Other

Please explain

Name of School

What Grade in School?

CONTACT INFORMATION

Parent/legal/Guardian First Name

Parent/legal/Guardian Last Name

Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Relationship to Client?

Client Email

Home Number

Work Number

Cell Number

Type of Setting

Home
Group Home
Foster Home
Psychiatric Hospital
Other

Please specify

INSURANCE/PAYMENT INFORMATION

Family Solutions accepts Medicaid (Cardinal Innovations & Sandhills). Please note at this time that referrals for IHTS can only be from Alamance, Rockingham, and Davidson Counties (Cardinal Innovations Counties).

Type of Insurance

Medicaid
NC Healthchoice
Private
Self-Pay

Do You Have Secondary Insurance?

Yes, I have other insurance
NO

What County is Your Medicaid?

Private Insurance Name

Insurance ID #

Secondary Insurance Name

Secondary Insurance ID #

REFERRAL SOURCE INFORMATION

Complete this section so we can contact you after the referral has been made.

Name

How did you hear about us?

Mailing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Phone

Has the Client or the Caretaker been informed of the referral?

MENTAL HEALTH INFORMATION

Current Medication

Current DSM V Diagnosis

Diagnosing Professional's Name & Phone

Any medical information staff should know about the client (IE: Allergies, Medical Conditions)

IHTS ENTRANCE CRITERIA: In order to qualify for in-home therapy services, traditional office-based outpatient treatment services were previously attempted, but were found to be inappropriate or not effective. There is also a need for linkage and/or coordination with other service systems. Appropriate referrals are for individuals with complex clinical needs that traditional outpatient cannot adequately address. Based on this criteria, please explain how the child is appropriate for IHTS.

REASON FOR TREATMENT: Briefly describe the reason the child is in need for IHTS.

DESIRED TREATMENT OUTCOMES: Describe the results you want for the child from receiving IHTS services.

Any additional information or request you'd like to provide us (Therapist preferences, former client with agency, siblings in attendance with agency, type of therapy)

Use this to upload additional documentation you want to send with referral.

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PLEASE NOTE: After you hit submit below, a copy of the form will be emailed to you for you records.

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IHTS REFERRAL FORM

Thank you for sending us an IHTS referral!