Community Service Program Waiver Submission Form

At Be. we make every effort to connect our clients with the services they seek and that are best fitting to their needs. That is why one of our goals is working with Community Service Programs that support clients in this process . If your family works alongside a Community Service Program such as Children's Long-term Support (CLTS) or IRIS you are in the right place.

Please take some time and fill out the waiver form provided thoroughly so we can begin to better understand what your needs are and how we can best support them. Once we receive the form we will reach out to you to solidify associated details and scheduling. Once we have a full understanding of how we can best serve you we will contact your service provider directly to obtain pre authorization for services.

If you have any questions, please let us know by emailing Carey Sorenson, PhD at be@beholisticcenter.com.

Waiver Submission Form

Client Name

Name of client enrolled with support services

First Name

Last Name

Client Age

Client Date of Birth

YYYY

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Individual Making Inquiry

Please also include relation to client

Parent(s) Name

First Name

Last Name

Parent(s) Phone Number

(###)

###

####

Parent(s) Email Address

Does the client have any siblings who are looking to use waiver services?

Yes

If so, please enter their name(s) and age(s) here

Do we have consent to contact your case provider?

Yes

Case Provider Name

First Name

Last Name

Case Provider Email

Case Provider Phone Number

(###)

###

####

Waiver Provider

CLTS, IRIS, etc.

Services Desired

Please specify all services, groups, or offerings that your client would like to attend using the waiver.

Desired Number of Sessions

Reason for Seeking Service(s)

Additional Considerations

Is there any relevant information about your child that we should consider and be aware of prior to them attending?