IIH Online Referral Form

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Date of Referral

Name of Individual being Referred

Age

Gender

Identifies As

Date of Birth

Parent/Legal Guardian

Phone Number (of Parent/Legal Guardian)

Email (of Parent/Legal Guardian)

Confirm Email

Region

Current MCO (Primary Insurance)

Aetna
Anthem
Magellan Healthcare
Sentara Community Plans

Medicaid #

Address

Address Line 1

City

State

Zip Code

Referral Source

Relationship to Referral

Referral Source Phone Number

Referral Source Email

Referral Source Fax Number

Is Referral currently receiving Case Management Services?

Name and Phone Number of Case Management Services provider (if applicable):

URBAN 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

This question is for ULLCFS Staff Use Only (all Others may select N/A)

Agency
Self
N/A

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/or
Referral exhibits such inappropriate behavior that documented, repeated interventions by the mental health, social services, or judicial system are necessary resulting in being at risk for out of home placement; and/or
Referral exhibits difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior resulting in being at risk for out of home placement

Please 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 Upload

Add file 1

Click or drag a file to this area to upload.

Comment

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Hampton, VA 23666

757-224-8017

757-224-8094

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Newport News, VA 23606