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Home
About
Referral Information
More
Residential
Crisis Response & Respite
Outpatient
Education Advocacy & Support
Jobs
Blog
Employee Information
IBHS Referral Information Form
Referral Information Forms for IBHS Programming
IBHS Program Referral Form
Residential Program:
Secure Residential
Leggiadro Center for Growth and Dev. (Psych Res)
Outpatient Program:
Day Psychiatric Rehabilitation
Community Support
Outpatient Therapy
Referring Agency Information
Referring Individuals Information
(Required)
First
Last
Agency
(Required)
Phone
(Required)
Email
(Required)
Date of Intake at Referring Agency
(Required)
MM slash DD slash YYYY
Contributing Factors Leading to Referral?
(Required)
Client Information
Client Information
(Required)
First
Last
Gender
(Required)
Male
Female
Non-binary
My gender isn't listed
Prefer Not to Answer
Preferred Pronouns:
Social Security Number
(Required)
Birthday
(Required)
MM slash DD slash YYYY
Employment Status
(Required)
Active Military Duty
Disabled
Employed Full Time
Employed Part Time
Not Employed
Retired
Student
Unkown
Region
(Required)
One
Two
Three
Four
Five
Six
Phone
(Required)
Preferred Language
(Required)
Race
(Required)
American Indian or Alaska Native
Asian or Native Hawaiian or Pacific-Islander
Black or African American
Middle Eastern or North African
White
Unknown
Decline to answer
Ethnicity
(Required)
Hispanic or Latino
Not Hispanic or Latino
Unknown
Decline to answer
Marital Status:
(Required)
Highest Level of Education:
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Contact Information
Contact Type
(Required)
Attach ALL Guardianship/Payee/Conservator Paperwork to Referral
Guardian
Payee
Conservator
Self
Name
(Required)
First
Last
Relationship to Client
(Required)
Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Emergency Contact:
Name
(Required)
First
Last
Phone
(Required)
Insurance/Benefit Information
Insurance/Payment
(Required)
Medicaid
Medicare
Dual Complete Plan
Private Pay
VA Benefits
Region Funded
Medicaid Type:
Nebraska Total Care
United
Molina
Region Responsible for Funding:
One
Two
Three
Four
Five
Six
Subscriber ID
(Required)
Attach all current insurance card copies and benefit award letters regarding income sources
Group Number
Social Security Benefits Amount:
(Required)
Social Security Income Amount:
(Required)
Aide to Aged, Blind & Disabled (AABD) amount:
(Required)
Other Sources of Income:
(Required)
Mental Health and Substance Use Information
Current Diagnoses
(Required)
Recent Information
(Required)
Acts of suicide attempts in last 30 days
Second Acts of self-harm in last 30 days
Any restraint in last 30 days
Medication compliance in last 30 days
Aggression/Assaults within the past 90 days
Substance Use History
(Required)
Yes
No
Substances Used:
Add
Remove
Nicotine Dependency
(Required)
Yes
No
Previous Treatment History
(Required)
Previous treatment - mental health, substance use, outpatient, therapy, detox.
Add
Remove
Mental Health Board Commitment
(Required)
Mental Health Board Commitment paperwork must be attached
Yes
No
County of commitment
Add
Remove
Medical Health Information
Medical Contidtions
(Required)
Add
Remove
Check all that apply:
(Required)
Drug Allergies
Food Allergies
Environmental Allergies
No known Allergies
Allergies:
Add
Remove
Check all that apply:
Diabetes
Heart Disease
Pregnant
Check all that apply:
Mobility Concerns
Physical Injuries
Memory Concerns
Scheduled Injection
Explain:
Frequency & Date of last injection
Current Providers:
(Required)
Add
Remove
Upcoming/Scheduled Appointments
(Required)
Provide any current lab work within six months of referral date
Add
Remove
Family History
Family History
(Required)
Major Mental Illness
Incarceration
Substance Use/Abuse
Criminal Involvement
Military Service
None
Any of the following:
Assistance needed for bathing
Assistance needed for dressing
Assistance needed for money management
Primary Supports:
(Required)
Add
Remove
Documentation Needed:
Latest psychiatric evaluation
(Required)
Max. file size: 256 MB.
Release of Information to referring agency
(Required)
Max. file size: 256 MB.
Medication list
(Required)
Max. file size: 256 MB.
Release of information to pharmacy
Max. file size: 256 MB.
Guardianship/Payee Information
Max. file size: 256 MB.
MHB Commitment Paperwork
Max. file size: 256 MB.
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