IHT/Therapeutic Mentor Referral Form Please check desired services IHT Services Intensive family therapy for children with acute concerns Therapeuc Mentoring Services Please include a copy of last CANS & Treatment Plan Client: ____________________________________ DOB: ________________ Age: _____ Gender: _______________ Address: _______________________________________ City/Town: ____________________ Zip Code: ___________ Phone: _________________ Race: ________________ Ethnicity: ____________ Smoker/Frequency: _____________ Special needs (linguisc/cultural): _____________________________________________________________________ Diagnosis: ________________________________________________________________________________________ School: ___________________________________ Address: _______________________________________________ Parent/Legal Guardian: _____________________________________________ Phone: _________________________ Referring Person/Agency: ___________________________________________ Phone: _________________________ Reason for referral/Jusficaon for IHT (Why individual therapy alone is insufficient): ___________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Goals of treatment: ________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Insurance Provider: __________________________________ Insurance ID#: _______________________ Secondary Insurance: ________________________________ Insurance ID#: _______________________ Client’s Primary Care Physician Name: _______________________________________ Phone: ____________________ Address: ___________________________________________ City: _________________________ Zip: ____________ OFFICE USE ONLY FAX TO: (781) 843-2403 Referral Date: _________________ Nikki Lemont, LICSW Sarah Benson, LICSW F: (781) 843-2403 First Contact Aempt: __________________________________ Voice message Leer Spoke with ________________ Second Contact Aempt: ________________________________ Voice message Leer Spoke with ________________ First date spoke to contact: ___________________ Appointments offered: __________________________________ Date assigned: __________________ AHA MR#: ____________________________ RU#: _________ CBHI Referral rev. 12/19, 12/20, 3/1/2021