Short-term Acceptance and Commitment Therapy (STACT) Request for Services

Short-term Acceptance and Commitment Therapy (STACT) Request for Services

Telehealth Only
Today's Date*

MonthDayYear
Date
Client's Name:*

First NameLast Name
How old is the client?*
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 Client:
How did you hear about us?
Case Coordinator Name (if applicable):

First NameLast Name
Case Coordinator Phone Number (if applicable):
Please enter a valid phone number.
Case Coordinator Email Address (if applicable):
example@example.com
Please tell us any other important information about the client and/or their family:
For Example: "Client is struggling with sleep.", "Client's time is split between two households.", etc.
Primary Insurance Provider/Funding Source:*
Member ID Number:*
Client's Date of Birth:*

MonthDayYear
Primary Insurance Provider/Funding Source Phone Number*
Please enter a valid phone number.
Is the client enrolled in Minnesota Medical Assistance?

YesNo
If yes, what is the ID Number?
Available days/times for scheduling
Should be Empty: