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

Other
Ethnicity
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Email Address
Please enter a valid 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?
Early Interventionist Name

First NameLast Name
Early Interventionist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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:
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)
Child's Date of Birth

MonthDayYear
Date
Sex Assigned at Birth
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.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.
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?
HIDDEN Child's Date of Birth:

MonthDayYear
Should be Empty:

Request for EIBI Services - South Carolina

Contact Information

Service Information

Insurance Information