IHBT - The Centers

IHBT Counseling Referral

Terry Raimond

IHBT Manager
216.434.2034

Demographic Information for Potential Client

First Name(Required)

Middle Initial

Last Name(Required)

Parent/Guardian Full Name(Required)

Youth’s Date of Birth(Required)

Social Security Number (SSN)

Street Address(Required)

City(Required)

State(Required)

ZIP Code(Required)

Phone Number(Required)

Parent/Guardian Email

Best Time to Contact

Insured?(Required)

Type of Insurance

Member ID/Subscriber ID

What was the youth's CANS Assessment Score?(Required)

If their score is a ‘1,’ this referral is inappropriate.

Has this youth been connected with IHBT services in the past 12 months?(Required)

Yes

If yes, what is the remaining time allowed by Aetna for IHBT services?(Required)

Please provide any additional information about the potential client and their care:

Client Gender

Parent/Guardian Gender

Client Race

Parent/Guardian DOB

Client Ethnicity

Parent/Guardian SSN

US Citizen?

Reason(s) for Referral – Problems/Concerns related to: (Please check all that apply.)

Additional Programs Currently Open

Children’s Service

Juvenile Court

Psychiatry

Other

Children's Services Worker Name(Required)

Children's Services Worker Phone(Required)

Juvenile Court Worker Name(Required)

Juvenile Court Worker Phone(Required)

Psychiatry Agency/Clinician Name(Required)

Psychiatry Agency/Clinician Phone(Required)

Program Name(Required)

Program Phone(Required)

Please describe concerning behaviors, emotions, and cognitions that place youth and/or others at risk:

Previous Mental Health Services

Please list any previous mental health services that the youth has participated in:

Agency Name

Worker Name

Dates

Agency Name

Worker Name

Dates

Agency Name

Worker Name

Dates

Parental Consent

NOTE: This form cannot be submitted without parental/guardian consent

Have you contacted the parent/guardian about your concern?(Required)

Date of contact(Required)

Date of consent(Required)

Explain the outcome of parent contact

Please provide your information so we may contact you regarding this referral:

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Title/Relationship to Client(Required)

Organization(Required)

This field is for validation purposes and should be left unchanged.

Circle Health Services Tax ID #23-7078501 | Cleveland Christian Home Tax ID # 34-0733131 | The Centers for Families and Children Tax ID # 23-7084455

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IHBT Counseling Referral

Terry Raimond

Demographic Information for Potential Client

Please provide any additional information about the potential client and their care:

Previous Mental Health Services

Parental Consent

Please provide your information so we may contact you regarding this referral:

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