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In-Home Referral Form

Intensive In Home (IIH) is a Medicaid funded service. Youth must have active coverage from Medicaid or have services funded through a Purchase Order from another source (such as FAPT, CSA etc.)

Intensive In Home Eligibility Criteria:
  • Youth is under the age of 21 and has the ability to understand and benefit from services.
  • Youth must have a mental, behavioral, or emotional illness which causes significant challenges in the home and/or community.
  • Youth is at risk of being placed outside of the home into a setting such as a hospital, foster care, residential treatment facility, juvenile detention, etc.
    • Youth is considered At Risk when experiencing at least 2 of the following 3 criteria:
      1. Has extreme difficulty maintaining positive, appropriate relationships with family, peers, authority figures, and/or others.
      2. Consistently has difficulty recognizing personal danger and/or inappropriate social interactions/behaviors.
      3. Has a history of repeated, ineffective, and/or unsuccessful interventions by other services.
  • The family must be willing to be available and involved in services which take place primarily in the youth’s home at an intensive level up to 10 hours per week.
  • The youth requires more intensity than outpatient clinic care OR services in the home are more likely to be successful than in a clinic.
To refer youth who meet the above criteria to IIH Services, please complete the following info:

Referral Information

Youth Details

Parent/Guardian Details: