HomeMy WebLinkAboutihbs-referral-form-english
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2000 Embarcadero Cove, Suite 400
Oakland, Ca 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
Intensive Home Based Services (IHBS)
Referral and Authorization Form
Instructions:
• Please complete this form.
• Attach the most recent ICC/IHBS Child and Family Team (CFT) Client Care Plan and Meeting
Minutes form.
• Email the completed packet or any questions to ICCAdministrator@acgov.org
Date: Person Referring: Agency
Phone# Email:
CLIENT INFORMATION
Client’s First Name: Last Name:
GENDER IDENTITY SmartCare#
Male Female Transgender Other: DOB:
Ethnicity: Preferred Pronouns:
Client’s Primary Language English Spanish Other:
Family Primary Language English Spanish Other:
Client’s Current Address:
City: Zip Code: Client Phone#
Current School Current Grade: Special Ed
Current Caregiver: Relationship Phone#
Name of Legally Responsible Party: Relationship:
Phone#
Date of most recent ICC Service:
Date of CFT meeting that recommended IHBS referral:
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JUSTIFICATION FOR IHBS
1. Describe the behaviors that interfere with the achievement of a stable and permanent family
life:
2. Describe in detail the behavior(s) or mental health conditions that interfere with the youth’s
functioning in school and/or the community:
eg. Describe behaviors that interfere with youth’s independent living objectives in terms of:
Achieving youth educational objectives in an academic program in the community or seeking and
maintaining a job
3. How will IHBS support the ICC/IHBS Client Care Plan goals?
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CHILD AND FAMILY TEAM MEMBERS (AS OF DATE OF REFERRAL) – IF AVAILABLE
Team Member Name Telephone# Email
Intensive Care Coordinator (ICC)
Mother(s)
Father(s)
Social Worker
Foster Parent(s)
Non-relative Extended Family
Member (NREFM) or Guardian
Therapist
TBS Worker
Family Partner
STRTP/Group Home Contact
EBCLO Attorney
Other (please specify)
(For office use only)
ACBH DETERMINATION
Client meets IHBS Eligibility criteria. Approval dates:______________________
Client does NOT meet IHBS criteria
Reason(s):
ACBH Administrator Signature Printed Name Date