BELIEF Eclectic New Client Need Assessment Form
Welcome to Belief Eclectic Learning Michigan premier ABA Clinic. We're happy that you've chosen us your service provider. Please complete the document below, so that we may assess your needs. Answer each question to the best of your ability. Feel free to message us at Admin@beliefeclecticlearning.com with any questions, comments or concerns.
Email address *
I hereby authorize necessary parties and affiliates, employees and agents (collectively), to release to B.E.L.I.E.F. Eclectic Learning allowed access to my personal health information (e.g., information relating to the diagnosis, treatment, and health care services provided or to be provided to me and which identifies my name, address, social security number, except the following information about me.
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