Mentor Behavioral HealthRequest for Services

Mentor Behavioral Health

Request for Services

Please use this form to submit a referral for services or to get in contact with a member of our team.

If you are interested in learning more, please contact us at 800-244-4691

Requested Service Information

Requested Service State*

Maryland Institute for Family Centered Services, Inc.

Ohio Mentor services

Pennsylvania Mentor services

South Carolina Mentor services

In Maryland, behavioral health services are provided by Institute for Family Centered Services, Inc., a part of the Sevita family.

Ohio Mentor Services*

Case Management

Diagnostic Evaluation/Assessment

Group counseling

Individual counseling

Intensive Home-Based Behavior Health Treatment (IHBT)

Medication Management

School Based counseling

Pennsylvania Mentor services*

Certified Peer Support

Intensive Behavioral Health Services (IBHS) / ABA

Intensive Case Management (ICM)

Family Based Services (FBS)

Group ABA

South Carolina Mentor Services*

Family Centered Treatment

Reason for Referral*

Preferred Delivery Method*

Office Based

Telehealth

School

Outreach to Home

No Preference

Hybrid

Preferred Delivery Time

Morning / Afternoon 9 am – 3 pm

Evening After 3 pm

Email address to be used for Telehealth*

Person to be Served Information

Enter information for the person served to be referred for services

First Name*

Last Name*

Date of Birth*

Gender

Female

Male

Other

Unknown

Primary Contact Phone*

Phone

Secondary Contact Number

Phone

Person Served or Legal Guardian Email Address*

Address*

Please include building/Apt #’s if applicable

City*

State/Province/Region*

Select

Postal/Zip Code*

Language(s) Spoken by Person Being Served

Referral Source Information

Referring Agency Business Name (if applicable)

Referral Source Name*

(person ie. Referring Physician name)

Person Filling Out Form

* If different from above

Referral Source Contact Phone Number*

Phone

Insurance Information

Primary Insurance Name*

Primary Insurance Policy #*

Do you have Secondary Insurance?*

Yes

No

Secondary Insurance Name

Secondary Insurance Policy #

Parent/Legal Guardian Information

First Name

Last Name

Relationship to Person to be Served

Mother

Father

Spouse

Legal Guardian/Custodian

Child

Foster Parent

Other

Please describe relationship to Person to be Served*

Primary Phone #

Phone

Language(s) Spoken by Parent(s)/Guardian

Service Information

Assistance needed with*

Hearing

Mobility

Vision

None

Any Special Requests?

How did you hear about us?*

Social Media

Ads

Flyer

Website

Google Search

Other

Social Media

Facebook

Instagram

LinkedIn

Psychology Today

Ads

Facebook

Instagram

LinkedIn

Psychology Today

How did you hear about us?

Example: Advertising leaflet/flyer, word of mouth, existing or previous person being served, community event/open house, or something else!

Additional Person Served information may be attached below

Drag and drop files here or

Send me a copy of my responses

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