• Home
  •  / 
  • IHBT Referral Form

IHBT Referral Form

Please complete the following form to submit a referral for Beech Brook's Intensive Home-Based Treatment program.

For a print version of the form, click here.

For a Microsoft Word fillable form, click here.

Yes
No
Aggression (arguing, forcing submission, bullying, fighting, stealing)
Disruptive Behavior (defiance, noncompliance in school/home/community, not following rules)
Hyperactive Behavior (tantrums, disturbing others, excess energy)
Withdrawn Behavior (prefer being alone, non-participation, unresponsive to social initiations, not talking with others)
Depressed Mood (overall sadness, low/restricted activity levels, crying, poor appetite)
Anxiety (acting in a fearful manner, appears overly stressed, inability to cope with daily functioning)
Other

Sign Up

Never miss out on the latest from Beech Brook.

Not now, maybe later.

Share This Page

Photo Gallery

1 of 22