In-Home & Outpatient Referral | Lizotte Clinical, LLC

Secure Submission Note: Please return completed forms via secure transmission. For questions regarding service eligibility, contact your clinical team.

1Service & Referral Information

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Service Requested *

Direct Treatment Services

Intensive In-Home Clinical TherapyAdolescent & Substance Use OutpatientIntensive In-Home PSBIntensive In-Home Substance UseIntensive In-Home Legal & Justice

Date of Referral *

Referral Source Name *

Agency *

Role / Relationship to Youth *

Phone *

Email Address *

2Family Readiness & Program Fit Checklist

To ensure a successful therapeutic match, please verify that the family understands and agrees to the following requirements prior to submission:

Ecological / Family Focus: Family understands that therapy works primarily with parents and caregivers to drive behavioral changes in the home and community environment.Caregiver Engagement: Family understands that work continues with caregivers even if the youth occasionally resists participation.Intensive Frequency: Family understands the expected session frequency (typically multiple times per week) and that consistency is vital for clinical progress.Service Coordination: Family understands they may need to pause overlapping individual outpatient services to focus on this intensive model.Placement Stability: Family and collaborative team agree to work toward maintaining the youth in their home setting for the duration of treatment.

3Youth & Family Demographics

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Current Residence Address *

Town / City *

State

Zip *

Legal Guardian(s) Name & Address *

Custody Status *

Guardian Phone *

Guardian Cell

Child Primary Language

Caregiver Primary Language

Interpreter Needed?

YesNo

Interpreter Contact Info (If Yes)

4Clinical Presentation & Behavioral History

Primary Diagnosis / Clinical Focus *

Diagnosis Provided By / Credentials

Date of Diagnosis

Developmental Delays, Autism, or ID?

YesNo

If yes, please explain:

Significant Physical Disabilities?

YesNo

If yes, please explain:

Primary Reason for Referral *

How are these behaviors currently affecting the family system?

5Service & System History

1. Current Living Situation: Is youth placed in residential treatment or foster/kinship care?

YesNo

2. Legal / Juvenile Justice Involvement:

YesNo

3. Prior Treatment History (Individual therapy, Section 28, HCT, MST, Residential, etc.):

4. Current Collateral Services Involved (Case Management, DHHS, Schools):

5. What outcomes would the parent and youth most like to achieve through treatment?

6Parent / Guardian Acknowledgment & Consent

To proceed with evaluation, the parent/guardian must check each acknowledgment and sign below:

I agree with the proposed intensive in-home child and family treatment services provided by Lizotte Clinical, LLC.I agree to actively participate in treatment, including family meetings, therapy sessions, and caregiver skill-building.I authorize the release of information contained within this application strictly for intake and treatment planning purposes.I acknowledge that services provided by Lizotte Clinical, LLC are private pay, and I accept financial responsibility for agreed-upon fees.I have reviewed all information in this document and attest that it is accurate to the best of my knowledge.

Parent / Legal Guardian Signature (Type Full Name) *

Date *

Private-Pay Clinical Screening & Referral Form

1Service & Referral Information

2Family Readiness & Program Fit Checklist

3Youth & Family Demographics

4Clinical Presentation & Behavioral History

5Service & System History

6Parent / Guardian Acknowledgment & Consent