Therapeutic Foster Care/IAFT Referral Form

Therapeutic Foster Care/IAFT Referral Form

To expedite the referral process to one of our Therapeutic Foster Care or Intensive Alternative Family Treatment homes, please complete this referral form with as much information as possible. Any questions please feel free to contact the Director of Residential Services, Denike Davis at denike.davis@integratedfamilyservices.net.

Referring Person/Agency*

Referring person phone number*

Referring person email*

Client name*

Client date of birth*

Service requested*

Select or enter value

Is there anything else we should know about this child?

(Optional) Would this child benefit from a particular dynamic in the home, need special considerations, or have any specialty services needed for success? If so, please include here.

Date placement is needed*

File Upload*

Please include:

1) The child's most recent assessment recommending TFC or IAFT services, and

2) The treatment plan if the client has one, and

3) The Universal Child and Adolescent Placement and Referral Form (This can be located on any LME/MCO website, e.g. Trillium's at https://www.trilliumhealthresources.org/for-providers/nc-child-and-family-improvement-initiative)

As well as any additional information that you feel would assist in the placement process.

Drag and drop files here or

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