top of page

Family & Guardian Referral Form

If you are a family member or legal guardian and would like to explore services with Integrity Behavioral Care (IBC), please complete the information below. This form starts the conversation and helps our team understand your loved one’s needs.

Individual Information

Date of Birth
Month
Day
Year
Gender
Male
Female
Other
Prefer not to say

 

 

Guardian Information

Relationship to Individual

 

 

Services Requested

Select Required Services

 

 

About the Individual

 

 

Funding & Insurance

Primary Funding Source
Private Insurance
Medicaid/Public Funding
Self-Pay
Grant/Charity

 

 

Document Upload

Please upload any relevant medical records or referral letters (PDF or Images).

 

 

Consent

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Security Notice: Please do not upload highly sensitive identification or medical documents through this form. After you submit, a member of our team will contact you and provide a secure way to share any required records.

bottom of page