Be. Child and Adolescent Mental Health LLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Name of client

Age of Client

Parent and/or Guardian Name (if minor is client)

Address

Additional Email Address

Phone Number

What type of reminders do you prefer

Email, text, or both

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Are you seeking or interested in any Alternative and/or Complementary Services

ie., yoga, reiki, sound healing, CFT, etc

Preferred Clinician

Name

Administrative

Are there any parental consideration we should be aware of?

Custody or placement arrangements?

Name of Person Making Inquiry

Are you seeking WAIVER services (ie. through CLTS or IRIS Programing)

If yes, check all that apply. If no, skip to next section

For Client For Parent For Siblings

Do we have your consent to contact your WAIVER PROVIDER?

This allows us to initiate services

Yes No

Waiver Provider

IRIS, CLTS, etc

Waiver Provider County

Provider Name

Provider Email

Waiver Services Desired

Specify ALL that apply: Consultation, Therapeutic yoga, Reiki, CFT, Art Therapy, Parent Support and Training, etc

Reason for seeking services through Waiver System

If siblings and/or parents will participate in services SPECIFY NAMES and AGES

Billing & Payment

Insurance Provider

Include Primary, Secondary, Waiver Services, or HMO information

Specify Waiver Service Type

CLTS, IRIS, etc

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.