Client Intake Form (Adult Services)
After more than 40 years, BMC remains committed to serving adults with behavioral challenges and barriers to living the happiest and most independent lives possible. Our adult services are almost exclusively through the Agency for Persons with Disabilities, but we do have other ways in which we can potentially serve the needs of your loved one or a person you serve. We can best meet your needs by getting the following 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. 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.
Client Information
Client/Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Service Setting
*
Standard Group Home
Family Home
Supported Living
Behavior Focus Home
Intensive Behavioral Home
ADT
Community
Person Completing Form
*
WSC
Guardian
Other
Current APD Client
*
Yes
No
CDC Client
*
Yes
No
Current Residential Provider
*
Current Adult Day Training Program
*
Does this individual have a current service authorization for a behavioral assessment.
*
Yes
No
Does this individual have a current service authorization for a behavioral services.
*
Yes
No
Main Concern
*
Communication Skills
Problem Behaviors (e.g., tantrums, aggression, self-injury)
Self-care skills (e.g., toilet training, dressing, eating)
Socialization
Contact Information
Is the individual their own guardian
*
Yes
No
Parent/Guardian Name (if applicable)
First Name
Last Name
Parent/Guardian Phone Number (if applicable)
Please enter a valid phone number.
Parent/Guardian Email (if applicable)
example@example.com
Preferred Service Area
*
Tallahassee
Fort Lauderdale
Jacksonville
Waiver Support Coordinator (WSC) Name
*
First Name
Last Name
WSC Email
*
example@example.com
WSC Phone Number
*
Please enter a valid phone number.
Are you currently receiving ABA services
*
Yes
No
Please name the provider. If you are not currently receiving ABA services, but have received services in the past please list the provider. If you have never received ABA services indicate "none".
*
If you have a BMC BCBA who is already aware of this individual, please include his/her name:
Additional Comments/Concerns
0/100
File Uploads
To insure that your file is properly routed and increase response time please upload the following documents: Support Plan, Behavior Support Plan and/or Service Authorization
Support Plan
*
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