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Outpatient Form

Request Services – Outpatient Services Full Intake Form

This website is not intended to give clinical or medical advice. If you are experiencing an emergency or crisis, please go to your nearest hospital Emergency Department or call 911.

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 hear about Italian Home for Children?
What made you decide to choose this program at IHC?
Insurance Information
Insurance Type
Member ID:
Group #
Referral Source
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
- DCF
- DMH
- DDS
- DYS
- DOE
- Legal System
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
This field is for validation purposes and should be left unchanged.

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