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