South Carolina EIBI Request For Services Form

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*

MonthDayYear
Date
Child's Name:*

First NameLast Name
How old is the child?*
Address:

Street Address

Street Address Line 2

City

Zip Code
City:*

Street Address

Street Address Line 2

CityState

Zip Code
Diagnosis (if known):*
Primary Language:
If Behavioral Dimensions calls you, is an interpreter needed?
Contact Name:*

First NameLast 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 NameLast 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:*

MonthDayYear
Primary Insurance Provider/Funding Source Phone Number*
Please enter a valid phone number.
Is your child enrolled in South Carolina Medicaid or Tefra?

YesNo
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 pm12:30 pm - 4:30 pm
Should be Empty:

Behavioral Dimensions Early Intensive Behavioral Intervention Request for Services South Carolina