CBHI Intake Form - Italian Home for Children

Service Requested*

In-Home Therapy
Therapeutic Mentoring
In-Home Behavioral

Client Name

First Last

DOB*

Age*

Gender*

Parent/Guardian (Name & Relationship)*

Joint/Legal Custody (if parents are separated)

Home Address

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

Cell Phone

Home Phone

Name of School Currently Attending

Primary Language*

Fluent in English*

Yes
No

Race*

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White

Current Services?*

Legal Guardian Name (if different from above)

DCF Agency (if DCF has custody)

Address

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

Home Phone

Work Phone

Cell Phone

Referral Source

Agency Name & Location*

Name*

First Last

Title*

Work Phone*

Cell Phone

Email*

Back-up/Supervisor Name

First Last

Phone*

How did you hear about Italian Home for Children?

What made you decide to choose this program at Italian Home?

Insurance Information

Managed Care Entity*

Plan Type*

MassHealth Standard
CommonHealth
Commercial

Policy Number (12 digits)*

Other Providers

Current/Former IHC Client (yes/no)*

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

State Agency Involvement?

DCF
DMH
DDS
DYS

Worker's Name and Number if applicable

Current DSM 5 Diagnosis (with ICD 10 code(s):*

DSM 5 (F code):*

Reason for referral / Goals for service*

Family/Guardians

Is the family aware of and in agreement with being referred? What is the family hoping to get from the service?*

Who lives in the home (name/relationship to the child)*

Please specify current challenges/potential goals for service(s)?*

Comments: known time constrained, safety issues, medications, allergies, etc.

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Phone

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Referral Form

Referral Source

Insurance Information

Other Providers

Family/Guardians