NEW CLIENT REGISTRATION:

Please complete the following form so that we may determine the best way to serve you and your family. 

• NEW CLIENT NEED ASSESSMENT FORM 
  

INTAKE FORMS:

For your convenience the following intake forms may be accessed and printed using the links below.  To expedite the process please complete the intake form prior to your arrival. Any questions related to registration and intake may be forwarded to [email protected]

• SOCIAL INTAKE QUESTIONNAIRE
  
• HIPAA RELEASE
• ABA INTAKE FORM
• SICK POLICY/MEDIA RELEASE

IF A THERAPIST IS UNABLE TO MAKE AN APPOINTMENT DUE TO SICKNESS  OR UNFORESEEABLE CONCERNS, CLIENTS HAVE THE OPTION TO CONTINUE TREATMENT WITHIN 48HRS WITH A NEW THERAPIST OR AWAIT REGULAR THERAPIST RETURN.

IF YOU ARE SICK AND UNABLE TO MAKE YOUR APPOINTMENT PLEASE INFORM US AS SOON AS POSSIBLE. Failure To provide 24hr notice will result in the following charges:

MISSED APPOINTMENT: A missed appointment fee of $25.00 will be charged to your account for a regular visit. Repeated Missed Appointment may result in discharge from our program.

Signing of all documents is voluntary. Rights are reserved by all consumers to revoke authorization of consent.   The refusal to sign will not affect client eligibility for benefits or enrollment or

payment for or coverage of services.

ENVIRONMENT:

Therapists have the right to refuse providing services due environmental concerns including family illness, communicable concerns or pest infestation.

INCLEMENT WEATHER POLICY:

B.E.L.I.E.F. Eclectic Learning may be closed due to inclement weather. If appointments are canceled due to weather conditions, you will be contacted prior to scheduled appointment. Posting of closing will be listed on our website and local news stations.