Get started · Beehave Portal

Family intake & consent

This is the first step toward starting services with Beehave. Once you submit, our admin will review and reach out within one business day.

Child

Child's first name:

Child's last name:

Child's date of birth:

Parent / guardian

Parent/guardian first name:

Parent/guardian last name:

Email:

Primary phone:

Address

Street address:

Apt / suite (optional):

City:

State:

ZIP:

Secondary contact (optional)

Secondary contact name:

Relationship:

Secondary phone:

OK to send appointment reminders by SMS:

Funding

How will services be funded?

Services & medical Services your child is currently receiving

Diagnosis (if any):

Behaviors of concern:

Allergies:

Other medical conditions:

Other considerations:

Pets in the home:

Child's interests:

Child's fears or triggers:

Anything else you'd like us to know:

Consent for evaluation

Beehave Service Team needs your consent to perform an initial evaluation. You'll sign additional agreements (HIPAA, ABA service, payment, cancellation policy) inside the portal once your account is approved.

I consent to a Beehave clinician evaluating my child for ABA services.

Signature