All information submitted on this referral form is completely confidential, secure and encrypted. After you submit the referral form, you will be emailed a copy for you records.
PLEASE NOTE: This referral form is only for professional providers looking to refer qualifying individuals to our IHTS program. If you are a parent, please use our Self-Referral form. In order to qualify for in-home therapy services, traditional office-based outpatient treatment services were previously attempted, but were found to be inappropriate or not effective. There is also a need for linkage and/or coordination with other service systems. Appropriate referrals are for individuals with complex clinical needs that traditional outpatient services cannot adequately address.
For specific questions about entrance criteria, please call Samantha Dunn @ 336-899-8800 ext. 17.