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

Other
Ethnicity
Address

Street Address

Street Address Line 2

City

Zip Code
City

Street Address

Street Address Line 2

CityState

Zip Code
County
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Email Address
We will contact you using this email address.
Relationship to Child
Preferred Language(s)

Other
Do you need an interpreter for scheduling?
How would the primary contact person prefer to be contacted about services?
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.Format: (000) 000-0000.
Case Manager Email Address
example@example.com
Service Information
My child is available for the times listed below Monday-Friday:
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.
File Upload

Cancelof
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)
Diagnosis (if known)
Child's Date of Birth

MonthDayYear
Sex Assigned at Birth
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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)
Child's Date of Birth (hidden)

MonthDayYear
Should be Empty:

Request For EIBI Services - Minnesota

Contact Information

Service Information

Insurance Information