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Applied Behavior Analysis
(ABA) In-Clinic Therapy
ABA In-Home Therapy
(ABA) In-School Therapy
(ABA) In-Community Therapy
Behavioral Parental Training
Consultations / Intake Process
Social Skills Therapy
Programs
Applied Behavior Analysis
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Check the waitlist services the applicant is applying below
Consultation/Intake
Diagnostic Services
Applied Behavior Analysis (ABA) In-Home Therapy
Applied Behavior Analysis (ABA) In-School Therapy
Applied Behavior Analysis (ABA) In-Clinic Therapy
Applied Behavior Analysis (ABA) In-Community Therapy
Applied Behavior Analysis (ABA) Social Skills Therapy “Bee Buddies”
Behavioral Parent Training (BPT)
Organizational Behavior Management (OBM)
Cognitive Behavioral therapy (CBT)
Dialectical Behavior Therapy (DBT)
Psychodynamic Therapy
Psychotherapy
Counseling
Play Therapy
Speech Therapy
Occupational Therapy
Physical Therapy
Music Therapy
Art Therapy
Personal Fitness Training
Medical nutrition therapy (MNT)
Pet Therapy
Service Animals
Respite Care
Au Pair
Transportation Services
Interpreter Services
Blindness Support Services
Deaf and hard of hearing Support Services
Services for the mobility-impaired
Evidence based Acupuncture
Evidence based Massage Therapy
Developmental Services
Transitioning into adulthood Services (TDS)
Disability Rights Legal Services
Other
Other:
Applicant Name
*
Applicant Nickname (if applicable)
Sex
Male
Female
Home Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Applicants Legal Guardian’s Name (if applicable)
Phone Number
*
Work Number
Employer
Occupation
Email
*
Best way to be contacted?
*
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
Insurance
Private Pay
Primary Insurance Name
Policy Number
Group Number
Responsible Party/Policy Holder Name
Date of Birth
Social Security Number
Secondary Insurance Name
Policy Number
Group Number
Responsible Party/PolicyHolder Name
Date of Birth
Social Security Number
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 Therapy
Occupational Therapy
Physical Therapy
Psychological Therapy
Other
Other
Is the applicant toilet trained?
Yes
No
Is the applicant on any special diets?
Yes
No
Any medications the applicant is currently taking
Yes
No
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?
Confidential Channel Communication Request
*
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.
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.
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.
*
I have read the above statement and understand Beehave Therapies Policy.
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.
Applicant’s Signature
*
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Date
Legal Guardian’s Signature (if applicable)
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Date
*
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Beehave Therapies
Los Angeles, CA
323-450-7533
