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.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Parent/Guardian 2 Email*
example@example.com
Preferred Service Location*

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

ClinicHomeSchool
Location of Service (check all that apply)*

HomeSchool/Day Care
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
Primary Insurance (please note that we do not accept: Humana Medicaid, Florida Community Care Plan, Aetna Better Health Medicaid, CareSource, United Medicaid, AmeriGroup, Molina, Oscar, CHAMPVA or Tricare.*

Aetna (Commercial)AnthemAPD MedwaiverBlue Cross Blue Shield PPOCHPFlorida BlueGeorgia Medicaid SSIKatie Beckett WaiverPeach StateSafety NetSimply/CarelonSimply SMMC Plan (excludes FL KidCare plans)Sunshine CMS (T19, T21, and Foster Care)United Healthcare (Commercial only - no UMR)Private Pay
Primary Insurance*

Virginia MedicaidPrivate PayOther
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
Do you receive funding through the "Step up for Students grant" (for Florida residents)"*

YesNo
Please provide the "Step up for Students grant" ID Number*
Private Pay Financial Agreement – SUFS

Process
To receive reimbursement through SUFS, parents will receive an invoice from BMC to be paid through the SUFS system. The parents are responsible for entering the billing information into their SUFS portal. When it is successfully entered into the system, BMC will be alerted the payment has been entered and submitted for our approval. Note: the process is now initiated by the parents, and this should be done as soon as possible following the receipt of the invoice from BMC. Families should expect this invoice to be sent through email on file to the parent. For use of SUFS for copay amounts, the invoice will be delivered to the family after the insurance processes the initial claim. For any questions about the SUFS system, please email Ms. Rhonda Luttrell at rluttrell@bmcsoutheast.com.

As it will be noted in your award information, these grants extend from July 1 to June 30. As a result, claims for the prior fiscal year are due no later than July 31. Therefore, claims that are not in the SUFS system by that time may not be payable, so it is important to get the claim information in as soon as possible at this time of year. The family will be responsible for any claim that is not entered in a timely manner, resulting in a denial due to the lapse of time across fiscal years. Please see all information from your SUFS grant award regarding timely processing of claims for payment.

Rates
BMC is dedicated to quality services provided by quality providers at the level of experience and credentialing determined by the lead BCBA to be the most appropriate for successful delivery of Behavior Analysis services. Therefore, your BMC team may include several therapists with different levels of credentials and experience. Any specific names are listed as current options, but may change based on clinical need or other changes which will be communicated with the family at least 30 days in advance of the change.
1. Lead/Consulting BCBA – $100/hr – Work conducted by the BCBA will include supervision of the RBT services at no less than 5% of scheduled RBT hours in addition to parent training, consultation with the RBT, data analysis and report writing.
2. Direct RBT services - $50/hr – Work conducted by the RBT is direct and active treatment. There may be some time associated with data analysis, entry and programming, which will reduce the cost of the BCBA conducting such necessary work.
**Data analysis and programming, as a necessary component of behavior analysis services, will be billed on an hourly basis either during times scheduled for therapy at the clinic/home, or off site a times not scheduled for therapy.

Time, Method and Manner of Payment
BMC currently uses an online system (Intuit QuickBooks Online) for invoicing, billing, and payments. You will receive your invoice through email. It will say in the subject line, “Invoice from Behavior Management Consultants.” If there is a particular email address you want these sent to, we recommend a personal email versus a work email, due to spam filters. Please email that information to ldurkin@bmcsoutheast.com. You can also add bmcoffice@bmcsoutheast.com to your contact list so that may prevent invoices going to spam.

*Following the first full month of services, please check your “spam folder” to make sure you are receiving your invoices. If not, please contact ldurkin@bmcsoutheast.com.
Signature for SUFS Financial Agreement*
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*

Cancelof
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*

Cancelof
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)*

Rows	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)*

Rows	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