News & Publications

IACCT Inquiry Form

(Disclaimer: Parent/Legal Guardian should be aware of any Inquiry made to IACCT)

If there is an immediate safety risk for this member please contact 911.

Today’s date *

Name of person making Inquiry *

Contact info for person making Inquiry – Phone Number *

Contact info for person making Inquiry – Email *

Alternate Contact Person *

Alternate Contact Phone Number *

Alternate Contact Email *

Relationship to Youth *

Youth’s Name *

Youth’s Date of Birth *

Youth’s Medicaid Number (if known)

Youth’s Address *

Name of Legal Guardian(s) *

Phone Number of Legal Guardian(s) *

Legal Guardian’s Locality (city or county) *

Does the Legal Guardian need interpreter services? *

Yes
No

Is the youth in foster care *

Yes
No

Is this youth currently involved with their local Family Assessment and Planning Team (FAPT) *

Yes
No

Briefly, what is the reason for this Inquiry? *

What other services or treatment prior to this Inquiry has been attempted? *

Is the youth currently in a psychiatric or substance use inpatient facility? *

Yes
No

Where does the youth currently reside? *