Thank you for your interest in services at Beacon Pediatric Behavioral Health!

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To help you understand the new client intake process, please read below:

*  We request that new client inquiries be sent via the form below so that we have all of the information required to  ensure that you are scheduled for the appropriate service and the provider that can best meet your needs.

*  You will receive a confirmation EMAIL that your new client intake request has been successfully submitted.  If you do not see this email within 24 hours, please check your spam box.

*  The Executive Director and Assistant Director personally review each new client inquiry to better understand your clinical needs and to match your case with the most appropriate provider.  Administrative meetings occur twice a week to allow for new client case reviews and assignments.

*  Dependent upon the day of your submission in relation to the timing of the next administrative meeting, please expect a reply from the intake coordinator within 2 to 5 business days.  For your convenience, the intake coordinator will respond VIA EMAIL, unless you specifically decline consent for email correspondence.  Again, please check your spam box if you do not receive an email within this time frame.

You are welcome to contact us via phone at any time; however, if no one is available to take your call, it is important that you leave a detailed message, including preferred call back times.  We do not have a full time receptionist on site, thus if you wish for a quicker response, you are encouraged to email the intake coordinator at info@beaconpediatric.com.

New Client Online Submission

Prevent Spam! Word Verification:
Who referred you/how did you find us?*
Your Name:*
Child's Name:*
Child's Date of Birth:*
Preferred method of communication (check all that apply; by marking your selection, you consent to BPBH sending you appointment information via the selected method)*
E-mail:*
E-mail confirmation:*
Phone Number:*
Please indicate the best days/times (during business hours) to contact you via phone:*
Address:*
What insurance will you be using?*
Insurance ID:*
Phone Number Listed on Back of Insurance Card:*
Please attach a photo of the front and back of your insurance card:
Please tell us about your current concerns/ the types of services you are interested in. *

If you are seeking Applied Behavior Analysis (ABA) therapy, please complete the information below:

Does your insurance policy cover ABA therapy services?
Has your child been diagnosed with Down Syndrome?
Has your child been diagnosed with an Autism Spectrum Disorder (ASD), such as Autism, Asperger's, etc.?
What severity level of symptoms has your child been identified with?
Who first diagnosed your child?
Approximately what date was your child first diagnosed with ASD?
Has your child ever recieved ABA therapy before?
Does your child receive special accommodations or supports in the school setting (Individualized Education Program [IEP], 504 Plan, Private School Service/Accommodation Plan, etc.)?

PLEASE NOTE: ABA coverage varies by insurance plan!
A diagnosis of an Autism Spectrum Disorder (e.g., Autism, Asperger's, etc.) is typically required for coverage, and certain restrictions apply.
Some insurance carriers have begun to cover ABA under the diagnosis of Down Syndrome.

PLEASE CHECK WITH YOUR INSURANCE COMPANY REGARDING REQUIREMENTS FOR ABA THERAPY IF YOU ARE UNSURE OF YOUR BENEFITS!


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Please keep in mind that communications via email and over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email or online form can be intercepted and read by other parties besides the person to whom it is addressed. By completing this form, you are confirming that you understand this and consent to communication with Beacon Pediatric Behavioral Health via email and over the internet.
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