IIH Online Referral Form - Step 1 of 2Date of Referral *Name *Age *Gender *Please SelectMALEFEMALEDate of Birth *Parent/Legal Guardian *Relationship to Referral *Region *Please selectRegion 4 (Richmond)Region 5 (Hampton) Phone Number *Medicaid # *Annual Medicaid Renewal Date *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReferral Source *Referral Source Phone Number *Referral Source Email *Referral Source Fax Number Is Referral currently receiving Case Management Services? *NoYesName and Phone Number of Case Management Services provider (if applicable):NextURBAN LEARNING AND LEADERSHIP CENTER FAMILY SERVICES INTENSIVE IN-HOME COUNSELING & MENTAL HEALTH SKILL-BUILDING SERVICES Screening/Admission Form INTENSIVE IN-HOME SERVICES (ages 20 and under)Please select at least 2 out of 3 from the following options as it pertains to the INTENSIVE IN-HOME SERVICES Referral INTENSIVE IN-HOME SERVICES Eligibility Criteria (1-3) Referral has difficulty establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community; and/orReferral exhibits such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary; and/or Referral exhibits difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior. At risk of acting in such a fashion that will cause harm to self or others.Please select all that apply from the following options as it pertains to the INTENSIVE IN-HOME SERVICES Referral *Difficulty managing angerFrequent anger outburstsDisruptive in community settingsConsistently withdrawn demeanorDisruptive in home settingRefusal to respond to redirectionExhibits manipulative behaviorsDisruptive in school settingLack of impulse controlDifficulty deescalatingFrequent crying spellsLimited ability to focusLack of empathyLow self-esteemDifficulty remaining seatedResorts to systems of violenceTruancyGang affiliation/involvementAbsence of mother or father or bothSubstance abuse (past/present)Fighting with parent/guardian, siblings and/or peersPrior arrest(s) or juvenile detentionSchool suspension or expulsionHygiene maintenance challengesDJJ, CPS or pending court involvementSevere anxiety or social phobiaNon-adherence to a prescribed medicationSuicidal ideationsSevere trauma/stress (neglect)Separation anxietyHomicidal ideationsSevere trauma/stress (abuse)Depression or grief/lossMutilation of self or animals or bothSevere trauma (family systems issues)Responds to reasonable requests with defiancePlease provide a brief description of the behaviors being exhibited by Referral (reason for service request)Please Upload any Documents such as • Individualized Education Plans (IEP's) • List of Medications • Physical Examinations • Psychological Evaluations • Discharge Documentation from Medical/Psychiatric Facilities • Psychiatric Evaluations • Etc... Number of Files to Upload12345678910Add file 1Add file 2Add file 3Add file 4Add file 5Add file 6Add file 7Add file 8Add file 9Add file 10PreviousPhone Submit Application