BAMHA Intake Forms - Italian Home for Children

Service Requested*

Individual Therapy
Family Therapy
Couples Therapy
Group Therapy
Other

Client Name*

First Middle Last

DOB*

Age*

Gender*

Parent/Guardian (if applicable)*

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Joint/Legal Custody (if parents are divorced or separated)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Home Phone

Work Phone

Primary Language*

Fluent in English*

Yes
No

How did you head about Italian Home for Children?

What made you decide to choose this program at IHC?

Insurance Information

Insurance Type

Member ID:

Group #

Referral Source

Online Website
Agency/School/Primary Care Physician

Agency Name & Location

Work Phone

Current/Former IHC-BAMHA Client

Yes
No

If yes, please list program(s) and approximate dates)

State Agency Involvement

Yes
No

State Agency Selection

Worker's Name and Contact Number

Reason for Referral/Current Symptoms*

Prior History of Psychiatric Hospitalization

Yes
No

If yes, date of last hospitalization

If yes, duration of last hospitalization

If yes, reason for hospitalization

Current psychiatric medications

Current and/or prior mental health services*

Comments: known time constraints, special preferences for treatment, etc.

Please attach documents

Max. file size: 50 MB.

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Comments

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Request Services - Outpatient Services Quick Inquiry

Insurance Information

Request Services - Outpatient Services Full Intake Form

Insurance Information

Referral Source