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The Behavior Place Enrollment Form
Please fill out the form below to start the intake process.
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Email
*
Your email
Child's Name
*
Your answer
Parent/Guardian Name
*
Your answer
Language
*
Your answer
Gender
*
Your answer
Schedule Availability
*
Choose
Full-Day Program (8:00 AM - 3:00 PM)
After-Care Programs (3:00 PM - 6:00 PM)
Service Location
*
Please select "Home-Based" if you are only looking for home-based services.
Choose
Center-Based (Middletown, NY)
Home-Based
Child's Date of Birth
*
MM
/
DD
/
YYYY
Location
*
Please select your county
Choose
Duchess
Orange
Rockland
Sullivan
Ulster
Phone Number
*
Your answer
Name of Insurance
Your answer
Member ID Number
*
Your answer
Subscriber's Name
*
Your answer
Subscriber's D.O.B.
*
MM
/
DD
/
YYYY
Subscriber's relationship to patient
*
Choose
Parent
Self
Sibling
Insurance Phone Number
Provider phone number found on the back of the card
Your answer
Referred By
*
Your answer
A copy of your responses will be emailed to the address you provided.
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