Intensive Home -Based TreatmentThank you for reaching out to The Centers about a potential referral for services. Please enter referral information below and a member of our team will be in touch with you soon.Counseling Referral Demographic Information for Potential ClientFirst Name(Required)Middle InitialLast Name(Required)Parent/Guardian Full Name(Required)Youth’s Date of Birth(Required) Month Day YearSocial Security Number (SSN)Street Address(Required)City(Required)State(Required)ZIP Code(Required)Phone Number(Required)Parent/Guardian Email Best Time to ContactInsured?(Required)YesNoType of InsuranceMember ID/Subscriber IDWhat was the youth's CANS Assessment Score?(Required)23If their score is a '1,' this referral is inappropriate.Please provide any additional information about the potential client and their care:Client GenderMaleFemaleNon-BinaryParent/Guardian GenderMaleFemaleNon-BinaryClient RaceWhiteBlack/African AmericanAsianAlaskan NativeAmerican IndianNative HawaiianUnknownParent/Guardian DOB Month Day YearClient EthnicityHispanic/LatinoNon-Hispanic or LatinoUnknownParent/Guardian SSNUS Citizen?YesNoUnsureReason(s) for Referral - Problems/Concerns related to: (Please check all that apply.) Dramatic change in behavior Worries Grief Fears Sadness Always tired Motivation Withdrawn Trauma Self-image/confidence Nervous/anxious Aggression/Anger Fighting Lying Bullying Disrespectful Defiant Hurts self Suicidal Impulsive Easily distracted Stealing Destruction of Property Sexual Acting Out Peer Relationships Social Skills Personal Hygiene Family Concerns Academics Truancy OtherAdditional Programs Currently Open Children’s Service Juvenile Court Psychiatry OtherChildren'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 ServicesPlease list any previous mental health services that the youth has participated in:Agency NameWorker NameDatesAgency NameWorker NameDatesAgency NameWorker NameDatesParental ConsentNOTE: This form cannot be submitted without parental/guardian consentHave you contacted the parent/guardian about your concern?(Required)YesNoDate of contact(Required) Month Day YearAcknowledgement of consent The parent/guardian has consented to moving forward with this referralDate of consent(Required) Month Day YearExplain the outcome of parent contactPlease 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)EmailThis field is for validation purposes and should be left unchanged. Terry RaimondIHBT Manager 216.434.2034