Get Behavior Care Specialists Client Information Sheet 2016-2026

Completing the Behavior Care Specialists Client Information Sheet online is essential for ensuring that all necessary information is accurately captured for effective care. This guide will provide you with step-by-step instructions to help you fill out the form easily and efficiently.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to obtain the Behavior Care Specialists Client Information Sheet and open it in your preferred editor.
2. Begin by entering the client information, including last name, first name, age, and date of birth. Make sure all details are accurate and complete.
3. Next, fill in the gender and grade of the client, followed by their street address, city, state, and zip code.
4. Provide information about the primary diagnosis, including the date of diagnosis, the doctor's name who made the diagnosis, and the clinic where the diagnosis was made.
5. If applicable, fill in the secondary diagnosis and any other conditions, again including the dates of diagnosis for these.
6. Complete the legal guardian information section by providing their full name, relationship to the child, address, city, occupation, employer, work phone, email, and preferred method of contact.
7. If there is an additional legal guardian, replicate the information needed in the corresponding fields.
8. List the client's siblings with their names, ages, and genders.
9. Fill out the emergency contact section, ensuring to include their name, relationship to the client, home phone, work phone, cell phone, and address.
10. Proceed to the child school/placement information section and indicate the type of organization, filling in the necessary details such as the name, address, city, state, zip code, phone, years attended, placement, contact person, and their contact details.
11. In the primary source of funding section, specify whether it is through insurance, private pay, or other means and provide all relevant details such as insurance carrier, phone, member ID, group number, policy holder's name, date of birth, and social security number.
12. Follow up with the secondary source of funding, filling out the type of funding, case manager, beneficiary's information, and all appropriate details.
13. Complete the referral information, including the individual's name making the referral, agency details, address, phone number, and email.
14. Fill out the medical information section, detailing the primary physician, clinic, and any relevant medical conditions, allergies, or medications the client may have.
15. Provide any additional medical treatment history if necessary, and include any developmental history that may impact care.
16. Document any family history of mental health conditions, legal issues, and community resources currently in use.
17. Complete the current treatment section concerning speech services, occupational therapy, physical therapy, and other services, ensuring all fields are filled accurately.
18. Lastly, note any current concerns in various areas such as academic, behavioral, communication, daily living skills, medical, and motor skills.
19. Review all entries for accuracy before saving your changes, downloading a copy, printing the form, or sharing it as necessary.

Start filling out the Behavior Care Specialists Client Information Sheet online today for effective care and management.