Client Intake Form (Children Services)

Client Intake Form (Children Services)

The beginning of serving you and your family starts now. We can best meet the needs of your family by getting the correct information from you up front and in the most efficient way, so we have developed this Intake Form to help us speed along the process. Please provide as much information as possible, as this helps us to know your individual and unique needs and serve you quicker and better. Once completed and submitted, you will receive further information on the process and our Lead BCBAs will be in touch with you. Thank you for trusting BMC with your needs.
Client Information
Client/Patient Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Residence*

Street Address

County

CityState

Zip Code
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Is there a second guardian/point of contact*

YesNo
Parent/Guardian 2*

First NameLast Name
Parent Guardian 2 Phone Number*
Please enter a valid phone number.
Parent/Guardian 2 Email*
example@example.com
Preferred Service Location*

Tallahassee (Only serving Leon County)JacksonvilleFort LauderdaleBoca Raton/Delray BeachValdosta
Which specific neighborhood/area of town
Requested Location of Service (check all that apply)*

ClinicHomeSchool
Can the client verbally communicate*

YesNo
Main Concern (check all that apply)*

Communication SkillsProblem Behaviors (e.g., tantrums, aggression, self-injury)Self-care skills (e.g., toilet training, dressing, eating)Socialization
Main Concern Copy
Please provide additional details about your concern including settings where concern occurs (e.g., school, home), time of day (e.g. morning, evening), intensity (e.g. causing injury to others requiring medical attention, hitting others without leaving a mark), or any other pertinent details. *
Insurance, Diagnostics and Supporting Documentation
Insurance - Primary (please note that we do not accept Amerigroup, CareSource, or Tricare)*

AetnaAnthemBeacon Health OptionsBlue Cross Blue Shield PPOFlorida BlueCHPUnited Healthcare (Commercial)APD MedwaiverFlorida MedicaidGeorgia Medicaid SSIKatie Beckett WaiverPeach StateSafety NetSunshine HealthPrivate Pay
Insurance Policy Number*
Is the client a Family Support Services (FSS) client?*

YesNo
Please enter the client's Medicaid number (for insurance purposes)*
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
Insurance - Secondary*

YesNo
As secondary insurances process claims differently, we cannot guarantee BMC can file costs not covered by the primary insurance to the secondary insurance. However, we will do our best to explore this with you prior to services beginning.
Front of Secondary Insurance Card*

Cancelof
Back of Secondary Insurance Card*

Cancelof
Has your child undergone a diagnostic evaluation by a developmental pediatrician, child psychiatrist, child psychologist, or child neurologist?*

YesNo
STOP: If your child does not have a formal diagnosis by a developmental pediatrician, child psychiatrist, child psychologist or child neurologist BMC will not be able to provide services. Please obtain this documentation prior to completing the rest of this form.

EXCEPTION: IF CHP WITH DIAGNOSIS OTHER THAN AUTISM YOU MAY NOT NEED DIAGNOSITIC EVALUATION
Name of professional that completed the diagnostic evaluation (enter none if not known).*

First NameLast Name
What is the client's diagnosis*

AutismPDD/NOSADHDNot yet diagnosedOther
STOP: If your child does not have a formal diagnosis by a developmental pediatrician, child psychiatrist, child psychologist or child neurologist BMC will not be able to provide services. Please obtain this documentation prior to completing the rest of this form.
Copy of Diagnostic Assessment*

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Do you have a copy of a Doctor Referral for Applied Behavior Analysis? (All FL Medicaid Plans require an MD/DO Signature on the referral)**

YesNo
STOP: If your child does not have a referral from a doctor for Applied Behavior Analysis BMC will not be able to provide services. Please obtain this documentation prior to completing the rest of this form.
Copy of Doctor Referral for Applied Behavior Analysis*

Cancelof
Are you currently receiving ABA services*

YesNo
Please name the provider*
Have you received ABA services in the past*

YesNo
Please name the past provider*
Do you receive any other therapies*

SpeechOTPTOtherWe do not currently receive any other therapies
Does the client attend school*

YesNo
Name of school*
Does the client have an IEP*

YesNo
Upload a copy of IEP*

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Does the client have a 504 plan*

YesNo
Upload copy of 504 plan*

Cancelof
What kind of classroom is your child in*

Self-contained classroomInclusive classroomMainstream classroomNot sure
Does the client attend after school care*

YesNo
What is the name of the after school care
Does the client attend day care*

YesNo
What is the name of the day care

Availability to attend ABA sessions at clinic/home, whichever is clinically recommended based on initial client evaluation (Do not operate on Saturday or Sunday)*

	Monday	Tuesday	Wednesday	Thursday	Friday
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm

Caregiver/Parent training is an essential part of ABA services, please indicate availability for caregiver training at the clinic/home, whichever is clinically recommended based on initial client evaluation (Do not operate on Saturday or Sunday)*

	Monday	Tuesday	Wednesday	Thursday	Friday
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm

Are you willing to deviate or have the ability to deviate from this schedule*

YesNo
Please share any additional details or important information that may affect scheduling.
How did you hear about Behavior Managment Consultants*

Referred by parent, friend, or clientReferred by medical professionalWebsearch (e.g., Google, Bing, etc.)Advertisement/BrochureOther
Referred by

First NameLast Name
Additional Comments/Concerns

0/100
Should be Empty:

Client Intake Form (Children Services)

Client Information

Insurance, Diagnostics and Supporting Documentation