Service Request Form

Client Name*

First NameLast Name

Client Birth Date*

MonthDayYear

Gender*

Insurance Provider *

Child's SSN:*

Name of Child's School: *

Parent/Caregiver Name:*

First NameLast Name

Parent/Caregiver Phone Number:*

Please enter a valid phone number.

Parent/Caregiver Email: *

example@example.com

Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Diagnosis:*

Dr who provided diagnosis:*

Primary Care Physician*

Describe the client: (age, school, grade...)*

Client's Strengths: *

Client's Weaknesses: *

Family Structure? Siblings? Living Arrangements? *

Birth History? (Normal pregnancy? Any complications?)*

Substance abuse/ mental health challenges/ family medical/behavioral history:*

Current Services/ Therapies? (Speech, OT..) (Are you receiving these in school or outside?) (Days and times received)*

Any current medications? *

Reason for referral? *

Impact of Behavior? (trouble going to the grocery store, movies, restaurants..)*

Appears to be most successful when...*

Target Behaviors? (gaining attention appropriately? Asking for help? What would you like them to be able to do?) *

Challenging Behaviors? *

	Does this occur? yes or no?	How many times per day does the behavior occur?
Screaming/ Crying
Throwing Items
Non-Compliance
Physical Aggression
Property Destruction
Self-Injury
Elopement
Flopping
Spitting
Throwing Object
Verbal Aggression

Any challenging behaviors not listed above that you would like to mention? *

Where will services be needed?*

Preference/ Favorite things: Favorite People? Items? Activities? *

Referred by? Where did you hear about Magnolia Behavior Solutions? *

REQUIRED DOCUMENTATION:

The following documentation is needed for a child to receive Behavior Analysis services through Medicaid and most commercial insurance providers. Additional documents may be required by commercial insurance providers.

1. Doctor Order for Behavior Analysis:

Referral written on prescription pad stating the client's name, DOB, ICD-10 code diagnosis, and must state "Referring for Behavior Analysis"
ICD-10 code diagnosis: Must be the most specific diagnosis code.
Signed by the referring Doctor

2. Comprehensive Diagnostic Evaluation (CDE)

Comprehensive Diagnostic Evaluations (CDE) are complete Biopsychosocial and Developmental Evaluations conductions by either:

Board certified/board eligible Developmental Pediatrician
Board certified/board eligible Child and Adolescent Psychiatrist
Board certified/board eligible Pediatric neurologist
Licensed clinical Child and Adolescent Psychologist

Please upload any required documentation here:

Service Request Form

Patient Medical History