Complete the Behavioral Consulting Intake Packet

This intake packet should be completed only if you are interested in receiving Behavioral Consulting services.

Relationship to Client: *

Today's Date: *

How did you hear about us? *

Client First Name: *

Client Last Name: *

Client Date of Birth: *

Contact Name: *

Address: *

Street address

City: *

State *

Zip *

Phone Number: *

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?

Behavioral Issues

Severity Scale: Consider all behavioral together when rating your need for service. 1= Occurs weekly; can be redirected if adult intervenes 2= Occurs a couple times a week; can be redirected with adult intervention 3= Occurs daily; an be redirected with adult intervention 4= Occurs daily; difficult to redirect even with adult intervention 5= Injuries occur to client or others; difficult to intervene

Aggression to others *

Self-injury *

Pica *

Property destruction *

Non-compliance *

Tantrums *

Other (describe):

Insurance and Funding Information

Primary Insurance Provider/Funding Source: *

Type N/A if none

Policy Number: *

Type N/A if none

Group Number:

Primary Insurance Provider/Funding Source Phone Number: *

Type N/A if none

Secondary Insurance Provider:

Policy Number:

Secondary Insurance Provider Phone Number:

Minnesota Medical Assistance/TEFRA/Other

Medical Assistance/TEFRA Number:

Waiver (DD, CADI, TBI)

School Contract:

Caseworker Contact

Caseworker Name:

Caseworker phone number:

Scheduling

Our services typically start in your family's home. Please check the hours, the client/family are available for services. Please check all that apply. We will be able to serve you more quickly the more availability you have.

8:00am-10:00am

Available

10:00am-12:00pm

Available

12:00pm-2:00pm

Available

2:00pm-4:00pm

Available

Important Information

Intake Disclosure: We appreciate your interest in receiving services from Behavioral Dimensions. Please note that we will only keep your intake form on file for one year from the date we received it. If you have previously submitted an intake packet and your wait has been longer than one year from the date you submitted your intake packet, please resubmit your information. If you are having difficulties with this form, you may call our office at 952-814-0207 to request that a hardcopy be sent to you.

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Complete the Behavioral Consulting Intake Packet

Service Location Information

Behavioral Issues

Insurance and Funding Information

Minnesota Medical Assistance/TEFRA/Other

Caseworker Contact

Scheduling

Important Information

Community Events

Questions About Services?

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