Eligibility for the Integrated Behavioral Health Home Component of Care
As a family already enrolled with Bergen's Promise, this form is to determine your child's eligibility for the integrated Behavioral Health Home component of care.   This would involve the addition of a nurse and certified Health/Wellness Educator to your Child and Family Team to assist you in better managing your child's chronic medical condition.  
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Email *
Parent/Caregiver Last name, First name *
Mobile number
Email address
My family is currently receiving services through Bergen's Promise *
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