Behavioral Dimensions IBI Intake Packet IBI Intake Packet Today's Date: Relationship to Client: Case Coordinator Contact Info: How did you hear about us? Client First Name: * Client Last Name: * Client Date of Birth: * Contact Name: * Address: * City: * State * Zip Code: * Phone: * Email Address: Diagnosis (if known): * Primary Language: Number of parents, siblings and others living in the home: Is your family in crisis? If so, what is the nature of your crisis? Aggression to others Self-injury Pica Property destruction Non-compliance Tantrums Other If you have chosen "Other", please (describe): Primary Insurance Provider/Funding Source: * Policy Number: * Group Number: * Primary Insurance Provider/Funding Source Phone Number: * I am available for the time periods listed below: 9:00 am - 12:00 pm 12:00 pm - 3:00 pm 3:00 pm - 6:00 pm If you are human, leave this field blank. Submit