Who is Eligible for IFI Services?
Services are provided to children and adolescents ages 5-21.

Children who enter our program have:

  • Severe behavioral, emotional, and/or substance abuse problems that need to be addressed IMMEDIATLEY.
  • They are at imminent risk to being removed from their current home, school.
  • The child may be at risk of harming themselves or someone else if the behavior continues.
  • The child has tried lower levels of care such as group therapy or individual therapy with little or no improvement.

Download Our Form

To request our help, please download the following document and answer the questions. This document will help us evaluate your needs and allow us to create a customized plan of action that will lead to your success.

YUC-Request-form.doc

Or Complete Our Electronic Form

Referral Form

Name:
SSN: - -
Address:
County:
Referral Date:
Referral Source:
Medicaid #;
Phone: - -
Ethnicity:
Gender: Male Female
Date of Birth:
Parent/Guardian/Representative:

Additional Contact(s)

Name:
Relationship: Teacher P.O. Relative Other
If other please specify:
Address:
Address 2:
Employer:
Phone: - - home
  - - work
  - - cell
  - - pager
 
Name:
Relationship: Teacher P.O. Relative Other
If other please specify:
Address:
Address 2:
Employer:
Phone: - - home
  - - work
  - - cell
  - - pager

Medical Information

Allergies: Yes No
If yes specify:
Seizures: Yes No
If yes specify:
Insurance #:
Present Prescribed Meds/Dosage/Frequency
Diagnosis: Primary Secondary Other
Judge Name (If Applicable):
Judge Number (If Applicable):