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Behavioral Health Managed Care Organization
New Patients
Consult | Alia Nationa
Events
About
Treatment
School
Parent
Contact
Careers
New Patients
Consult | Alia Nationa
Events
About
Treatment
School
Parent
Contact
Careers
CBM is Accepting
New Behavioral Health Patients
Specializing in Behavior Assessments
&
Autism Treatment
New Patient Contact form
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Patient Name
*
First
Last
Patient Date of Birth
*
Parent / Caretaker Name
*
First
Last
Relationship to Patient
Parent / Legal Guardian
School Administrator
Medical, Mental, Behavioral Health Provider
Email
*
Email
Confirm Email
Phone Number
*
Behavior Health Service Needs
*
Assessment
Treatment
Consultation
Best Session Times for client
Morning weekday (8-12pm)
Afternoon Weekday (1-3pm)
Evening Weekday (4-6pm)
Saturday (8-12 pm)
Preferred Treatment Setting
Clinic Outpatient
Home & Community (Daycare)
School
Payment / Insurance
*
Private Pay
AmeriHealth Caritas Delaware
Delaware First Health
Highmark Options Delaware
Aetna
TriCare
Highmark Delaware
Cigna
Commercial other
Existing Diagnosis
*
Autism Spectrum Disorder
Attention Deficit Hyperactive Disorder
Attention Deficit Disorder
Opposition Defiance Disorder
Anxiety
Depression
Post Traumatic Stress Disorder
Global Developmental Delay
Speech Delay
Other
none
Description of Behaviors
Aggression (Verbal , Physical, Spitting, Property Destruction, etc.)
Self Injury Behaviors (Head Banging, biting self, pulling own hair etc.)
Elopement (leaving designated area without permission)
Inappropriate Social Behaviors (inadequate play skills, inadequate peer relationships etc.)
Inappropriate Active Daily Living Skills (problems with toileting, eating, hygene)
Accommodations / Cultural Considerations
English Second Language
Religious / Spiritual Practices
Adaptive Equipment
Patient Treatment Email
Explain Accommodations / Cultural Considerations
Submit