Request For EIBI Services

Request For EIBI Services - Minnesota

This service is typically delivered to preschool-age children who will receive between 20-40 hours of service each week Monday through Friday between the hours of 8:00 a.m. and 4:00 p.m.
Today's Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
Preferred Name
(e.g., nickname, chosen name, etc.)
How old is the child?*
Race*

AsianWhiteBlack or African AmericanAmerican Indian or Native AlaskanPacific Islander or Native HawaiianPrefer Not to AnswerOther
Ethnicity*

Hispanic or LatinoNon-HispanicPrefer Not to Answer
Address*

Street Address

Street Address Line 2

City

Zip Code
City*

Street Address

Street Address Line 2

CityState

Zip Code
Check this box if your child spends time at another address.
Additional Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Information
Parent/Legal Guardian & Primary Contact*

First NameLast Name
Primary Contact Phone Number*
We will contact you using this phone number.
Primary Contact Email Address*
We will contact you using this email address.
Primary Contact's Relationship to Child*
Primary Contact
Parent/Legal Guardian

First NameLast Name
Phone Number
We will contact you using this phone number.
Email Address
We will contact you using this email address.
Relationship to Child
Preferred Language(s)*

EnglishSpanishAmharicSomaliHmongOther
Do you need an interpreter for scheduling?

YesNo
How would the primary contact person prefer to be contacted about services?*

Phone callEmailText messaging
IMPORTANT: By selecting email or text in the box above, you consent to receive emails and/or text messages from the referrals team at Behavaioral Dimensions for scheduling and receiving reminders/information to the selected person's phone number and/or email address listed above. Text message charges from your provider may apply.
How did you hear about us?
Case Manager Name (optional)

First NameLast Name
Case Manager Phone Number
Please enter a valid phone number.
Case Manager Email Address
example@example.com
Service Information
My child is available for the times listed below Monday-Friday:

8:00 am - 12:00 pm12:00 pm - 4:00 pm
Please tell us any important information about your child or family
For Example: "Child is struggling with sleep.", "Child's time is split between two households.", etc.
Insurance Information

The following information is required for billing insurance, and may be reported to the state.
What funding sources are available for the client's services? (select all that apply)*

Minnesota Medical AssistancePrepaid Medical Health Plan (PMAP) or Managed Care Organization (MCO)Primary Commercial InsuranceSecondary Commercial Insurance
Diagnosis (if known)*
Child's Date of Birth*

MonthDayYear
Sex Assigned at Birth*

MaleFemale
Minnesota Medical Assistance ID number (PMI):*
If possible, please take a photo of the FRONT of the Medical Assistance card...
and the BACK of your child's Medical Assistance card.
PMAP/MCO Carrier Name
PMAP/MCO Member ID Number
PMAP/MCO Group Number
If possible, please take a photo of the FRONT of the PMAP/MCO card...
and the BACK of your child's PMAP/MCO card.
Primary Commercial Insurance Provider*
Primary Group Number*
Primary Member ID Number*
Primary Phone Number*
Please enter a valid phone number.
Please take a photo of the FRONT of the Primary Commercial Insurance card...
and the BACK of the Primary Commercial Insurance Card.
Secondary Commercial Insurance Provider*
Secondary Group Number*
Secondary Member ID Number*
Secondary Phone Number*
Please enter a valid phone number.
Please take a photo of the FRONT of the Secondary Commercial Insurance Card...
and the BACK of the Secondary Commercial Insurance Card.
HIDDEN: Primary Language:
If Behavioral Dimensions calls you, is an interpreter needed?
Is your child enrolled in Minnesota Medical Assistance? (hidden)*

YesNo
Child's Date of Birth (hidden)*

MonthDayYear
Should be Empty:

Request For EIBI Services - Minnesota

Contact Information

Service Information

Insurance Information