Request for Assessment Services

Request for Assessment Services

All Assessments are conducted at our office in St. Louis Park, MN
Today's Date*

MonthDayYear
Date
Eligibility

Assessments are available for children aged 18-months to 17 years old for initial concerns around autism and other developmental challenges, or for a re-evaluation of an existing diagnosis.
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
Do you need an interpreter for scheduling?*

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

Phone callEmailText messaging
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 are your concerns? What do hope to learn from the assessment?
Please tell us any other important information about your child or 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)*

Primary Commercial InsuranceSecondary Commercial InsuranceMinnesota Medical Assistance
Does the child have a current medical or mental health diagnosis?*

YesNo
Diagnosis (if known)
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.
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.
HIDDEN - Is your child enrolled in Minnesota Medical Assistance?*

YesNo
HIDDEN - Child's Date of Birth*

MonthDayYear
HIDDEN - Does the child have a current medical mental health diagnosis?

YesNo
HIDDEN - Primary Language:
HIDDEN - Do you need an interpreter for scheduling?

YesNo
Should be Empty:

Request for Assessment Services

Eligibility

Contact Information

Service Information

Insurance Information