Enrollment Form - Beehave Therapies

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Consultations / Intake Process
Applied Behavior Analysis

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Consultation/IntakeApplied Behavior Analysis (ABA) In-Home TherapyApplied Behavior Analysis (ABA) In-School TherapyApplied Behavior Analysis (ABA) Clinic-Based TherapyApplied Behavior Analysis (ABA) Community-Based TherapyApplied Behavior Analysis (ABA) Social Skills Training (SST) “Bee Buddies”Applied Behavior Analysis (ABA) Employment TrainingBehavioral Parent Training (BPT)Family Sitter (Private Pay Only)Other

Other

Applicant Name *

Applicant Nickname (if applicable)

Sex: *MALEFEMALE

Home Address

Apartment, suite, etc

Country

City

State/Province

ZIP / Postal Code

Applicants Legal Guardian’s Name (if applicable):

Phone Number *

Work Number

Employer

Occupation

Best way to be contacted? Phone/Text/Email *

Email *

Applicant’s Secondary Legal Guardian’s Name (if applicable)

Phone Number

Work Number

Employer

Occupation

Email

Best way to be contacted? Phone/Text/Email

Emergency Contact Name

Relationship

Phone Number

Work Number

Applicant’s preference of service payment

InsurancePrivate Pay

Primary Insurance Name

Group Number

Policy Number:

Responsible Party/Policy Holder Name

Date of Birth

Social Security Number

Secondary Insurance Name

Policy Number

Group Number

Responsible Party/PolicyHolder Name

Social Security Number

Date of Birth

Main Physician/pediatrician Name

Other treating Physicians Names

Applicants Diagnosis (if applicable)

Age Diagnosed (if applicable)

Check the services the applicant is currently receiving (if applicable)

Applied Behavior Analysis (ABA)Speech TherapyOccupational TherapyPhysical TherapyPsychological TherapyOther

If Other

Is the applicant toilet trained?YESNO

Is the applicant on any special diets?YESNO

Any medications the applicant is currently taking

If there are any special considerations, we should know about please list them here and provide us with any documentation deemed necessary for those considerations:

What Are Your Primary Concerns for the applicant?

How did you learn about Beehave Therapies?

As required by the Health Information Portability and Accountability Act (HIPAA) of 1996, you have a right to request that communications concerning your personal health information be made through confidential channels. I hereby request the use of the following confidential channels for the communications of information related to my personal health, treatment, or payment for treatment. This request supersedes any prior request for confidential communications I may have made.

1- May we discuss your Child’s Personal Health Information with anyone else? (You must fill in the name and phone number if okay.) *

Beehave Therapies does not discriminate based on disability type or level, race, color, religion, sex or national origin. Diagnosis & Prescription for services must be received before services can begin for all insurance-based clients. Beehave Therapies holds the rights to release any client at any time due to extreme situations that may endanger the health or safety of staff or others. *

I have read the above statement and understand Beehave Therapies Policy.

Applicant’s Signature *

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Date

Legal Guardian’s Signature

Start signing your signature here

Date

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Beehave Therapies
Los Angeles, CA
323-450-7533

Check the services the applicant is applying to receive below: *

Beehave Therapies Los Angeles, CA 323-450-7533

Beehave Therapies
Los Angeles, CA
323-450-7533