Behavioral Dimensions Early Intensive Behavioral Intervention Request for Services South Carolina
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 4:30 p.m.
Today's Date
*
-
Month
-
Day
Year
Date
Child's Name:
*
First Name
Last Name
How old is the child?
*
Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
City:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Diagnosis (if known):
*
Primary Language:
If Behavioral Dimensions calls you, is an interpreter needed?
Contact Name:
*
First Name
Last Name
Phone:
*
Please enter a valid phone number.
Email Address:
*
example@example.com
Relationship to Child:
How did you hear about us?
Early Interventionist Name:
First Name
Last Name
Early Interventionist Phone Number:
Please enter a valid phone number.
Early Interventionist Email Address:
example@example.com
Please tell us any other important information about your child or family:
For Example: "Child is struggling with sleep.", "Child's time is split between two households.", etc.
Primary Insurance Provider/Funding Source:
*
Member ID Number:
*
Child's Date of Birth:
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
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18
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29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1996
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1994
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Primary Insurance Provider/Funding Source Phone Number
*
Please enter a valid phone number.
Is your child enrolled in South Carolina Medicaid or Tefra?
Yes
No
If yes, what is the ID Number?
My child is available for 3.5-4 hour shifts for the times listed below Monday-Friday:
8:00 am - 12:00 pm
12:30 pm - 4:30 pm
Submit
Should be Empty: