Behavioral Health Intervention Services Referral Form

We are happy to accept referrals and questions. Please contact us at:

(319) 286-4531 or

If you prefer, a PDF version of this form is available for download.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
  • Please include information about current symptoms, behaviors, functioning and trauma. Do these occur in the home, school, community, or across all settings?
  • Insurance & Documentation

    Please attach copy of insurance card and ABA documentation, if applicable, in upload section below. Insurance verification is required before appointment. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.
  • Drop files here or
    Accepted file types: jpg, pdf, png, gif.