Referral Intake Information | UMCF Family Services

IHBT Intake Form Columbus Area

"*" indicates required fields

Referred Client*

First Last

Date of Birth*

Contact Name (Parent/Guardian/Caregiver)

First Last

Contact Phone*

Is it OK to leave a message or text message?

Yes

Contact Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Service Request (check all that apply)

Intensive Home-Based Therapy

Home-Based Outpatient

Psychiatry/Medication Evaluation

Outpatient (office/telehealth)

Presenting problem (Anxiety, Trauma, Depression, Academic Concerns, etc.)

Managed Care Provider

Name of School

Referral Contact Name

Phone

County of Residence

How did you hear about UMCF?