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Home > Providers > Resources and information > Intensive Behavioral Health Services (IBHS) Forms

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)
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Our Address: 8040 Carlson Road, Harrisburg, PA 17112

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