Contact Us What are you waiting for?Let’s build your journey together. Send a MessageClick here to send a quick message to connect with our experts with questions about therapy, insurance, family support groups, etc. Patient Intake FormClick here to begin our process. Providing all requested documents will help expedite services for your child. Start Your CareerClick here to join our passionate team of BCBAs, RBTs, Academic Tutors, and Music & Art teachers. Send Us a Message Please enable JavaScript in your browser to complete this form. Name Comment Phone Name *FirstLastPhone *Email *Comment or Message *Custom Captcha * = Submit Talk To Us EMAILinfo@innocentbee.comhr@innocentbee.com PHONE NUMBER980-366-0813 Follow Us: Patient Intake Form Please enable JavaScript in your browser to complete this form.Getting to Know the Client Who will be receiving our services Client Name *FirstLastGender *Select oneMaleFemaleNon-binary of Available Upload Date of BirthReferred by *Diagnosis ReceivedAutismADD/ADHDOther Getting to Know the Family Parent/guardian information Parent/Guardian Name *FirstLastRelationship to Client *Marital Status *Select oneMarriedSingleDivorcedPrimary Email *Street AddressCityStateALALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWYZip Code *Cell Phone *Home Phone *Preferred NumberCell PhoneHome PhoneBest Time to CallMorningAfternoonEveningThe Paperwork This is the last part! Please choose the best days and times for your appointments, and provide your funding information below. Appointment Scheduling Available Days of the WeekSundayMondayTuesdayWednesdayThursdayFridaySaturdayBest Appointment Time *Second Best Appointment Time *Insurance Information Take pictures of the front and back of your insurance card and upload them below. Funding Source *Select oneMedicaidBCBSCignaAetnaUnitedOtherUpload Front of Insurance Card Click or drag a file to this area to upload. Upload Back of Insurance Card Click or drag a file to this area to upload. Custom Captcha * = Submit Start Your Career Please enable JavaScript in your browser to complete this form.Getting to Know You Personal information Your Name *FirstLastPrimary Email *Home PhoneCell Phone *Preferred NumberCell PhoneHome PhoneStreet AddressCityStateALALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWYZip Code * Current Qualifications & Availability Tell us more about yourself Current Qualifications *BCBARBTBehavior TechnicianFuture Behavior TechnicianOther and Explain below:Other QualificationBrief Bio *Please type a brief descripton of your experience specifically in the field of Behavior Analysis or working with children and adolescents with development disabilities.Primary Language *EnglishOtherCitizenship *I am a citizen of the United StatesI am not a citizen of the United States, but I am authorized to work in the U.S.Are You 18 or Older? *YesNo You Citizenship Are you looking for Part Time or Full Time? *Part TimeFull TimeWhen would you be able to start working? *Interview Scheduling Available Days of the WeekSundayMondayTuesdayWednesdayThursdayFridaySaturdayWhich days are best for you to be interviewed?Best Interview Time *Second Best InterviewTime *Background Information This is the last part! Upload Your Resume Click or drag a file to this area to upload. Upload your PDF or DOCx file.Reference 1FirstLastAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReference 2FirstLastAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCustom Captcha * = Submit
