Language
English (US)
Spanish (Latin America)
Haitian Creole
French (Canada)
French (France)
IHCS REFERRAL FORM
Referring Agency/Agent Information
Referring Agency Name
*
Name of Referring Agency
Referring Agent Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Participant Information
Participant Name
*
ex. First Mi Last
DOB
*
-
Month
-
Day
Year
ex. MM-DD-YYYY
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Housing Status
*
Please Select
Housed
Unhoused
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant Services Required
Please select all services required
Services Required
*
Psychiatric Care/Evaluations
Medication Management
Substance Abuse Counseling
Mental health Counseling
Housing
Case Management
SOARS Application
Medical /Primary Care
Mental Health Assessment
Substance Abuse Assessment
Participant Insurance Information
Please complete insurance information
Insurance Type
*
Carrier Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code
*
Member ID
*
Third Party Information
Please fill in below ONLY if client has a third party responsible for the care of the participant.
Caregiver Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Agency/Agent Additional Comments about this referral that will best assist the admissions coordinator.
File/Document Upload
Browse Files
Drag and drop files here
Choose a file
Files Type: pdf, docx, xlsx, mp4, jpg, jpeg, png
Cancel
of
*We Accept Admissions M-Th Only*
*THERE ARE NO ADMISSIONS ON FRIDAYS or WEEKENDS*
Submit
For Office Use Only
Appointment Date / Time
Assigned Provider
Please Select
Raquel D.
Dr. Moe B.F.
Amarilis P.
Sabina T.
Should be Empty: