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IHT/Therapeutic MentorReferral Form
Please check desired services
IHT ServicesIntensive family therapy for children with acute concerns
Therapeutic Mentoring ServicesPlease include a copy of last CANS & Treatment Plan
Client: ____________________________________ DOB: ________________ Age: _____ Gender: _______________
Address: _______________________________________ City/Town: ____________________ Zip Code: ___________
Phone: _________________ Race: ________________ Ethnicity: ____________ Smoker/Frequency: _____________
Special needs (linguistic/cultural): _____________________________________________________________________
Diagnosis: ________________________________________________________________________________________
School: ___________________________________ Address: _______________________________________________
Parent/Legal Guardian: _____________________________________________ Phone: _________________________
Referring Person/Agency: ___________________________________________ Phone: _________________________
Reason for referral/Justification for IHT (Why individual therapy alone is insufficient): ___________________________
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Goals of treatment: ________________________________________________________________________________
________________________________________________________________________________________________
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Insurance Provider: __________________________________ Insurance ID#: _______________________
Secondary Insurance: ________________________________ Insurance ID#: _______________________
Client’s Primary Care Physician Name: _______________________________________ Phone: ____________________
Address: ___________________________________________ City: _________________________ Zip: ____________
OFFICE USE ONLY
FAX TO: (781) 843-2403 Referral Date: _________________Nikki Lemont, LICSWSarah Benson, LICSWF: (781) 843-2403
First Contact Attempt: __________________________________
Voice message Letter Spoke with ________________
Second Contact Attempt: ________________________________
Voice message Letter Spoke with ________________
First date spoke to contact: ___________________ Appointments offered: __________________________________
Date assigned: __________________ AHA MR#: ____________________________ RU#: _________
CBHI Referral rev. 12/19, 12/20, 3/1/2021
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