EIBI Minnesota - Service Request Form

Request For EIBI Services - Minnesota

This service is typically delivered to preschool-age children who will receive between 20-40 hours of service each week Monday through Friday between the hours of 8:00 a.m. and 4:00 p.m.
Today's Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
How old is the child?*
Address*

Street Address

Street Address Line 2

City

Zip Code
City*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Information
Contact Name*

First NameLast Name
Phone*
We will contact you using this phone number.
Email Address*
We will contact you using this email address.
Relationship to Child*
How did you hear about us?
Case Manager Name (optional)

First NameLast Name
Case Manager Phone Number
Please enter a valid phone number.
Case Manager Email Address
example@example.com
Primary Language:
If Behavioral Dimensions calls you, is an interpreter needed?
Preferred Language(s)*

EnglishSpanishAmharicSomaliHmongOther
Do you need an interpreter for scheduling?*

YesNo
Who should be contacted first to discuss services?*

Contact personCase Manager
How would that person prefer to be contacted about services?*

Phone callEmailText messaging
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.
Service Information
My child is available for the times listed below Monday-Friday:

8:00 am - 12:00 pm12:00 pm - 4:00 pm
Please tell us any important information about your child or family
For Example: "Child is struggling with sleep.", "Child's time is split between two households.", etc.
Insurance Information
Diagnosis (if known)*
Child's Date of Birth*

MonthDayYear
Date
Primary Insurance Provider/Funding Source*
Member ID Number*
Child's Date of Birth:*

MonthDayYear
Primary Insurance Provider/Funding Source Phone Number*
Please enter a valid phone number.
Is your child enrolled in Minnesota Medical Assistance?*

YesNo
If yes, what is the ID Number (PMI)?*
If possible, please take a photo of the FRONT of your child's insurance card...
and the BACK of your child's insurance card.
Should be Empty:

Request For EIBI Services - Minnesota

Contact Information

Service Information

Insurance Information