Patient Form

The Beehavior Company for Autism Treatment

New Client Information for The Beehavior Company

(Fields marked with * are required.)

Prospective Client Information

First Name * Text value required

Last Name * Text value required

Birth Date * Text value required

Gender * Please select one option

Marital Status Prospective client's marital status

I am seeking services for * Please select one option

Services Requested

Main concern and reason for seeking services * Text value required

Services requested * Chose all that apply. Please see The Beehavior Company website for a description of services. Early InterventionChallenging behaviorsSocial SkillsDaily Living SkillsCaregiver TrainingToilet Training Checkbox mandatory

Are you interested in receiving services via online (telehealth) sessions? YesNo

Primary Guardian Information (Required for prospective clients under the age of 18)

Primary Guardian first name

Primary Guardian last name

Primary Guardian date of birth

Primary Guardian gender

Primary Guardian marital status

Primary Guardian relationship to prospective client

The prospective client’s parents are * Please select one option

Secondary Guardian Information (Required for prospective clients under 18, if applicable)

Secondary Guardian first name

Secondary Guardian last name

Secondary Guardian date of birth

Secondary Guardian gender

Secondary Guardian marital status

Secondary Guardian relationship to prospective client

Contact Information

Address * Text value required

City * Text value required

State * Please select one option

Zip / Postal Code * Text value required

Which phone number do you prefer for contact? * Please select one option

Home Phone

May we leave a message at your home phone number? * YesNo Choice mandatory

Cell Phone

May we leave a message at your cell phone number? * YesNo Choice mandatory

Work Phone

Work Phone Ext

Email * Your login information and additional forms will be sent to this email address E-Mail address value required

May we leave a message at your work phone number? * YesNo Choice mandatory

Additional Prospective Client Information

Does the prospective client have a diagnosis? * Yes No Choice mandatory

If yes, please specify

Did someone refer you to our services? * Please select one option

If you were referred, who made the referral? Type N/A if you were not referred

Is the prospective client prescribed medication? YesNo

If yes, please include names and dosages (#mg + times per day) of each medication and name of the physician who prescribed each

Insurance Information

Do you have insurance? * If no, please enter N/A in the following fields YesNo Choice mandatory

Subscriber name * Type N/A if not applicable Text value required

Primary insurance company * Type N/A if not applicable Text value required

Member ID * Type N/A if not applicable Text value required

Group ID * Type N/A if not applicable Text value required

Date of Form Completion * Text value required

Files

Drivers License Front

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Guardianship Documentation/ Parenting Plan

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Speech Referral from Pediatrician

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Insurance Card Back of card

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Official Behavioral Diagnosis Report, if any

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Drivers License Back

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Previous Psychological Evaluations, if any

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Insurance Card Front of card

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Other Any documents you think maybe helpful

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By submitting this form, I accept that the information entered will be used within the strict framework of my request* Checkbox mandatory

*These fields are mandatory

The Beehavior Company is committed to ensuring that the collection and processing of data carried out by our thebeehaviorcompany.com site complies with the General Data Protection Regulations (GDPR) and the Data Protection Act. To know and exercise your rights, particularly concerning the withdrawal of consent to the use of collected data, please consult our privacy policy

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