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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.

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Withdrawn Behavior (prefer being alone, non-participation, unresponsive to social initiations, not talking with others)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)

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