EIBI South Carolina - Service Request Form

Request for EIBI 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

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 / Province

Postal / 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*
Parent/Legal Guardian

First NameLast Name
Phone Number
Please enter a valid phone number.
Email Address
Please enter a valid email address.
Relationship to Child
Preferred Language(s)*

EnglishSpanishMandarinOther
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?
Early Interventionist Name

First NameLast Name
Early Interventionist Phone Number
Please enter a valid phone number.
Early Interventionist Email Address
example@example.com
Early Interventionist Agency
Service Information
My child is available for 3.5-4 hour shifts for the times listed below Monday-Friday:

8:00 am - 12:00 pm12:30 pm - 4:30 pm
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.
Insurance Information
What funding sources are available for the client's services? (select all that apply)*

Primary Commercial InsuranceSecondary Commercial InsuranceMinnesota Medical Assistance
Child's Date of Birth*

MonthDayYear
Date
Sex Assigned at Birth*

MaleFemale
Diagnosis*
Please upload a full diagnostic assessment from a licensed psychologist or physician. This is required before we can verify insurance benefits.

Cancelof
If you do not have a copy of the report, please list the agency that completed the diagnostic assessment and their contact information below.
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.
Medicaid Agency
Medicaid Member number (PMI):*
If possible, please take a photo of the FRONT of the Medicaid card...
and the BACK of your child's Medicaid card.
HIDDEN: Primary Language:
If Behavioral Dimensions calls you, is an interpreter needed?
HIDDEN: Is your child enrolled in South Carolina Medicaid or Tefra?

YesNo
HIDDEN Child's Date of Birth:*

MonthDayYear
Should be Empty:

Request for EIBI Services - South Carolina

Contact Information

Service Information

Insurance Information