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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.

MM slash DD slash YYYY
Client Name(Required)
MM slash DD slash YYYY
Client Address(Required)
Parent/Guardian Name(Required)
Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
Current Tanager Place client?(Required)
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.
Name on Medicaid/MCO Card:
Drop files here or
Accepted file types: jpg, pdf, png, gif, Max. file size: 256 MB.

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