The Behavior Place Enrollment Form
Please fill out the form below to start the intake process.
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Email *
Child's Name *
Parent/Guardian Name *
Language *
Gender *
Schedule Availability *
Service Location *
Please select "Home-Based" if you are only looking for home-based services.
Child's Date of Birth *
MM
/
DD
/
YYYY
Location *
Please select your county
Phone Number *
Name of Insurance
Member ID Number *
Subscriber's Name *
Subscriber's D.O.B. *
MM
/
DD
/
YYYY
Subscriber's relationship to patient *
Insurance Phone Number
Provider phone number found on the back of the card
Referred By *
A copy of your responses will be emailed to the address you provided.
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