Intensive Behavioral Health Services (IBHS) Forms

• FFT Booster Session Request Form (PDF)
• IBHS Discharge Summary Form (PDF)
• IBHS Fee-for-Service (FFS) to PerformCare Transition Form (PDF)
• IBHS Flexible Outpatient Therapy Registration Form (PDF)
• IBHS Individual/ABA Provider Choice Acknowledgment Form (PDF)
• IBHS Individual/ABA Provider Choice Acknowledgment Form Spanish (PDF)
• IBHS Initial Service Capacity Acknowledgement for Individual IBHS and ABA IBHS Form (PDF)
• IBHS Provider Choice Form — Capital (Cumberland, Dauphin, and Perry) (PDF)
• IBHS Provider Choice Form — Capital (Cumberland, Dauphin, and Perry) Spanish (PDF)
• IBHS Provider Choice Form — Capital (Lancaster and Lebanon) (PDF)
• IBHS Provider Choice Form — Capital (Lancaster and Lebanon) Spanish (PDF)
• IBHS Provider Choice Form — TMCA (PDF)
• IBHS Provider Choice Form — TMCA Spanish (PDF)
• IBHS Written Order Recommendation Guidelines (PDF)
• IBHS Written Order Form (PDF)
• Multisystemic Treatment (MST) Provider Choice Form (PDF)
• MST Provider Choice Form (Spanish) (PDF)

Jiva assessments

• IBHS Written Order/Best Practice Evaluation Receipt Notification Form (PDF)
• IBHS Assessment Registration Form (PDF)