Request for Behavior Therapy Services

Request for Behavior Therapy Services

For PBS-C, STACT, and FABS
Client Name*

First NameLast Name
Preferred Name & Pronouns (optional)
(e.g., nickname, chosen name, etc.)
How old is the client?*
Clients must be age 21 and under to qualify for these services.
Race*

AsianWhiteBlack or African AmericanAmerican Indian or Native AlaskanPacific Islander or Native HawaiianPrefer Not to AnswerOther
Ethnicity*

Hispanic or LatinoNon-HispanicPrefer Not to Answer
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check this box if the client spends time at another address
Additional Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
Primary Contact & Legal Parent/Guardian *

First NameLast Name
Primary Contact's Relationship to Client*
Primary Contact's Phone Number*
We will contact you using this phone number.
Primary Contact's Email Address*
We will contact you using this email address.
Parent/ Legal Guardian

First NameLast Name
Relationship to Client
Phone Number
Email Address
How did you hear about us?
Case Manager Name (if applicable)

First NameLast Name
Case Manager Phone Number
Please enter a valid phone number.
Case Manager Email Address
example@example.com
Preferred Language(s)*

EnglishSpanishAmharicSomaliHmongOther:
Do you need an interpreter for scheduling?*

YesNo
How would the primary parent/legal guardian prefer to be contacted about services?*

Phone callEmailText messaging
IMPORTANT: By selecting email or text in the box above, you consent to receive emails and/or text messages from the referrals team at Behavaioral Dimensions for scheduling and receiving reminders/information to the selected person's phone number and/or email address listed above. Text message charges from your provider may apply.
Service Information
What service(s) are you interested in?*

Positive Behavior Supports - Caregivers (PBS-C)Short-Term Acceptance and Commitment Therapy (STACT)Focused Assessment and Behavioral Supports (FABS)Unsure - I'd like to learn more about each program.
Available days/times for scheduling services with the primary caregiver*
What are the client's main behavior(s) of concern?*
What change do you hope to see throughout services? *
Please share 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.
Insurance Information

The following information is required for billing insurance and may be reported to the state.
Diagnosis (if known)*
Client's Date of Birth*

MonthDayYear
Sex Assigned at Birth*

MaleFemale
What funding sources are available for the client's services? (select all that apply)*

Minnesota Medical AssistancePrepaid Medical Health Plan (PMAP) or Managed Care Organization (MCO)Primary Commercial InsuranceSecondary Commercial InsuranceTraditional WaiverCDCS GrantSelf-PayOther
Minnesota Medical Assistance ID number (PMI):
If possible, please take a photo of the FRONT of the client's MA insurance card...
and the BACK of the client's MA insurance card.
PMAP/MCO Carrier Name
PMAP/MCO Member ID Number
for Primary Insurance
PMAP/MCO Group Number
for Primary Insurance
If possible, please take a photo of the FRONT of the client's PMAP/MCO card...
and the BACK of the client's PMAP/MCO card.
Commercial Insurance Provider
Commercial Insurance Group Number
for Primary Insurance
Commercial Insurance Member ID Number
for Primary Insurance
Commercial Insurance Phone Number
Please enter a valid phone number.
If possible, please take a photo of the FRONT of the client's commercial insurance card...
and the BACK of the client's commercial insurance card.
Secondary Commercial Insurance Provider
Secondary Commercial Insurance Group Number
Secondary Commercial Insurance Member ID Number
for Secondary Insurance
Secondary Commercial Insurance Phone Number
Please enter a valid phone number.
If possible, please take a photo of the FRONT of the client's secondary commercial insurance card...
and the BACK of the client's secondary commercial insurance card.
Waiver Type

CADI: Community Access for Disability InclusionCAC: Community Alternative CareDD: Developmental DisabilitiesOther
Waiver Agency or Organization
Waiver County
Waiver Case Manager or Contact Name

First NameLast Name
Waiver Case Manager Phone Number
Please enter a valid phone number.
Waiver Case Manager Email Address
example@example.com
Should be Empty:

Request for Behavior Therapy Services

Contact Information

Service Information

Insurance Information