Complete the IBI Intake Packet

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

Family Client Information

Case Coordinator's Please fill out contact info below
N/A if not a Case Coordinator
Street address
N/A if not known

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

Insurance and Funding Information

Type N/A if none
Type N/A if none
Type N/A if none

Minnesota Medical Assistance/TEFRA/Other

Scheduling

Our services typically start in your family's home. Our IBI program requires Monday-Friday availability from 8am-4pm for full-time services. We will be able to serve you more quickly the more availability you have. Please check below to confirm your availability. (Accommodations can be made for toddlers who takes naps.)

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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