Make an Appointment


To help you understand the new client intake process

please CLICK HERE

before completing the New Client Inquiry Form Below!

 

Please complete the form below in its entirety!  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; the intake coordinator will also follow up VIA PHONE to ensure the email was received, so please also be sure to check your voicemail regularly. 

If you do not hear from the intake coordinator within the time-frame above, PLEASE EMAIL INFO@BEACONPEDIATRIC.COM TO FOLLOW UP!


Your Name *
Your Name
Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Preferred Method of Communication *
Please check all that apply; by marking your selection, you consent to BPBH sending you appointment information via the selected method
Phone *
Phone
Address *
Address
Please select which insurance you will be using. If it is NOT listed here, unfortunately, we DO NOT accept your plan.
Please type in the ID number on your card; if you will be paying out of pocket simply write N/A
Tricare or Self Pay clients, please simply write N/A
Please describe your current concerns/the types of services you are interested in.
ABA THERAPY: *
Please check next to ALL that apply. If you are not seeking ABA therapy, please simply check the first box.
PSYCHOLOGICAL TESTING/ASSESSMENT/EVALUATION *
Please check next to ALL that apply. If you are not seeking testing, please simply check the first box.

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.