Request for BTS Services

Request for Behavior Therapy Services

PBSC, FABS, STACT
Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Preferred Name & Pronouns (optional)
(e.g., nickname, chosen name, etc.)
Race*

AsianWhiteBlack or African AmericanAmerican Indian or Native AlaskanPacific Islander or Native HawaiianPrefer Not to AnswerOther
Ethnicity*

Hispanic or LatinoNon-HispanicPrefer Not to Answer
Sex Assigned at Birth*

MaleFemale
Address*

Street Address

Street Address Line 2

City

Zip Code
City*

Street Address

Street Address Line 2

CityState

Zip Code
Check this box if the client spends time at another address.
Additional Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
Parent/Legal Guardian (Primary Contact)*

First NameLast Name
Primary Contact's Phone*
We will contact you using this phone number.
Primary Contact's Email Address*
We will contact you using this email address.
Primary Contact's Relationship to Child*
Parent/Legal Guardian

First NameLast Name
Phone
Email Address
Relationship to Child
IMPORTANT: By selecting email or text in the box above, you consent to receive emails and/or text messages from the referrals team at Behavaioral Dimensions for scheduling and receiving reminders/information to the selected person's phone number and/or email address listed above. Text message charges from your provider may apply.
Preferred Language(s)*

EnglishSpanishAmharicSomaliHmongOther
How would the primary contact person prefer to be contacted about services?*

Phone callEmailText messaging
Do you need an interpreter for scheduling your appointments?*

YesNo
Do you need an interpreter present (online/in-person) for your appointments?*

YesNo
Are you a referring provider or case manager?*

YesNo
Referrer Name

First NameLast Name
Referrer Email
example@example.com
Referrer Phone
Please enter a valid phone number.
Upload referral, ROI Consent, or other supporting documention

Cancelof
Case Manager Name (optional)

First NameLast Name
Case Manager Phone Number
Please enter a valid phone number.
Case Manager Email Address
example@example.com
Service Information
What service(s) are you interested in?*

Positive Behavioral Supports for Caregivers (PBSC)Focused Assessment & Behavioral Supports (FABS)Short-Term Acceptance and Commitment Therapy (STACT)Unsure, I'd like to learn more about each program
Available days/times for scheduling services with the primary caregiver:*
What are the client's main behavior(s) of concern?**
What change do you hope to see throughout services? **
Please share any other important information about the client and/or their family.
For Example: "Child was referred by our pediatrician.", "Child has an educational diagnosis.", etc.
Insurance Information

The following information is required for billing insurance and may be reported to the state.
Have you received Early Intensive Developmental and Behavioral Intervention (EIDBI) services (also called ABA therapy) from a Minnesota provider in the past year?*

NoYesUnsure
What funding sources are available for the client's services? (select all that apply)*

Minnesota Medical AssistancePrepaid Medical Health Plan (PMAP) or Managed Care Organization (MCO)Primary Commercial InsuranceSecondary Commercial Insurance
Does the child have a current medical or mental health diagnosis?*

YesNo
Diagnosis (if known)
Minnesota Medical Assistance ID number (PMI):*
Please take a photo of the FRONT of your child's Medical Assistance card...
and the BACK of your child's Medical Assistance card.
PMAP/MCO Carrier Name*
PMAP/MCO Member ID Number*
PMAP/MCO Group Number*
Please take a photo of the FRONT of your PMAP/MCO card...
and the BACK of your PMAP/MCO card.
Primary Commercial Insurance Provider*
Primary Group Number*
Primary Member ID Number*
Primary Phone Number*
Please enter a valid phone number.
Please take a photo of the FRONT of your child's primary insurance card...
and the BACK of your child's primary insurance card.
Secondary Commercial Insurance Provider*
Secondary Group Number*
Secondary Member ID Number*
Secondary Phone Number*
Please enter a valid phone number.
Please take a photo of the FRONT of your child's secondary insurance card...
and the BACK of your child's secondary insurance card.
How did you hear about Behavioral Dimensions? Did a provider refer you?
Should be Empty:

Request for Behavior Therapy Services

Contact Information

Service Information

Insurance Information