IHBT Referral Form

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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.

Youth Name

Current School

Grade

Address

Address 2

City

State

Zip

Phone Number

Email Address

Parent/Guardian Name

Was Parent/Guardian Notified of Referral?

Yes

Insurance Type

Name/Title of Person Initiating Referral

Email Address

Phone Number

Check all the concerns you have about the child:

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Withdrawn Behavior (prefer being alone, non-participation, unresponsive to social initiations, not talking with others)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

Please describe the reason for completing this referral

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IHBT Referral Form