Free-Bee Chat Intake Form

Thank you for your interest in our services.

In order to better understand your child’s specific needs, we kindly request that you complete the following intake form. All information provided will be kept confidential.

Parent/Guardian Information

Full Name

First Name

Last Name

Relationship to child

Email:

Phone Number:

Preferred Contact Method:

Preferred Language:

Child Information

Child's Full Name

First Name

Last Name

Age:

Diagnosis (if any):

Current School/Childcare Program:

Behavioral Concerns

Potty Training

Tantrums

Elopement/Running away

Self Injurious Behavior

Sleep Training

Speech Delay

Social Skills

Nutrition Goals

Other

If other, briefly describe your child's behavior needs/challenges or additional information below:

Have you previously sought professional assistance or therapies for your child's behavior needs? If yes, please provide details:

Referral and Scheduling

How did you hear about Happy Beehavior?

What are your preferred days and times for the free consultation? Please provide a few options:

Consent and Agreement: By submitting this intake form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that the free consultation does not establish a client-provider relationship, and any services beyond the consultation will require a separate agreement.

Please fill out the above information and submit the form. Our team will review your responses and contact you to schedule the free consultation. Thank you for choosing Happy Beehavior. We look forward to supporting you and your family.

Free-Bee Chat Intake Form

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