Home | Intensive In-Home Referral Form Intensive In-Home Referral Form Name(Required) First Last Date of Birth(Required) Month Day Year AgeGender Male Female Identifies asPhone Number(Required)Email(Required) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Individual Primary Language English Spanish Other Individual Primary Insurance Sentara Community Plans United Healthcare Parent/Guardian Name(Required) First Name Last Name Relationship Parent/Guardian Phone Number(Required)Please enter a valid phone number.Parent/Guardian Email example@example.comINTENSIVE IN-HOME SERVICES Eligibility Criteria (1-3)(Required) The individual struggles with relationships, putting them at risk of hospitalization or out-of-home placement due to conflicts with family or community. The individual shows inappropriate behavior requiring repeated interventions, such as suspension, hospitalization, residential treatment, intensive in-home or outpatient therapy, putting them at risk of out-of-home placement. The individual has trouble thinking clearly, making them unable to recognize personal danger or inappropriate social behavior, putting them at risk of out-of-home placement. Select all applicable challenges below for the Individual referred (check all that apply) Inability to avoid dangers/hazards Anxiety or Social Phobia Daily living skills Grief/Loss Hygiene Challenges Juvenile Justice/Court Involved Manipulative Behaviors Prior Arrests/ Juvenile Detention PRTF/Hospital Discharge Difficulty Managing Anger Community Linkage of Services Depression Gang Affiliation/Involvement Impulsive Behaviors Disruptive in Home and/or Community Settings Not Adhering to Prescribed Medications Phobia/s Safe living situation School suspensions or expulsion Self Harm Social Skills Low Self-esteem Truancy Suicidal ideations Sexual Trauma/ Abuse Frequent Fighting with Peers Consistently Withdrawn Self-Advocacy Skills Separation Issues Substance Use Severe Trauma/Stress Absence of mother/father or both Homicidal Ideations Fight with Parent/Guardian and/or Siblings Inability to Focus Please provide a brief description of the behaviors being exhibited by the individual being referred (reason for service request)(Required)Please provide a brief description of the challenging behaviors that have been observed.Name First Last Email Phone Number
