IHTS REFERRAL FORM

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 Chris Faulkner @ 336-899-8800 ext. 11.
CLIENT INFORMATION

CONTACT INFORMATION
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INSURANCE/PAYMENT INFORMATION
Family Solutions accepts Medicaid (Cardinal Innovations & Sandhills).  Please note at this time that referrals for IHTS can only be from Alamance, Rockingham, and Davidson Counties (Cardinal Innovations Counties). 
REFERRAL SOURCE INFORMATION
Complete this section so we can contact you after the referral has been made.
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MENTAL HEALTH INFORMATION
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PLEASE NOTE: After you hit submit below, a copy of the form will be emailed to you for you records. 

Thank you for sending us an IHTS referral!

We have received your IHTS referral information and our intake staff will contact you shortly. 

If you have not heard from us within two business days, please call us so we can stay on top of it. 

Family Solutions’ Intake Staff

231 N Spring St

Greensboro, NC 27401

336-899-8800 ext 10 

intake@famsolutions.org

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