IBI Intake Packet - Behavioral Dimensions

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?

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