Interest Form - Updated 10.12.2026

The Behavior Business LLC

Interest Form

Phone: (425) 293-2557
Email: jhaegele@thebehavior.biz

The Behavior Business LLC

Date Completed

Client Information

Client name

Client Date of Birth

What city/town does the client reside in?

Name of person providing information

Relationship to client

Email address

Contact phone number

Insurance Information

Type of Insurance Coverage

Private Insurance

Medicaid

Private and Medicaid

Private Pay

Name of Primary Insurance Company

Name of Secondary Insurance Company

Type N/A if this does not apply

Household/ Family Information

Parent Relationship Status:

Single

Married

Divorced/ Separated

Other

Primary language(s) spoken at home

Other languages spoken at home

Type N/A if this does not apply

Interpreter needed?

Yes

Language for interpreter (if yes)

Other information about your family (Cultural considerations, family dynamics, or anything else you want us to know about working with you)

Type N/A if this does not apply

Type of Service Requested (Sessions are based on staff availability, clinical necessity, and schedule openings.)

ABA Client services Please click all that apply

1:1 Sessions

1 CBT and 1 Client

Social Skills Ground

1 CBT and up to 5 Clients

ABA Parent Coaching services Please click all that apply

1:1 ABA Coaching Only

1 BCBA and 1 parent

Group ABA Coaching Only

1 BCBA and multiple parents

Service Location Requested (Please note that location is partially determined by staff availability and clinical necessity.) Please click all that apply

Clinic

Telehealth

School

In-Home

Must start in clinic first

Client Availability

Time block preferences Please click all that apply

Morning

9 AM - 12 PM

Afternoon

12:30 PM - 3:30 PM

Evening

4 PM - 6 PM

Days Available Please click all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Additional Information

If you had to pick one, what would be your primary focus for your child right now

Skill Acquisition Behavior Management

Major goals for the client

Is your child allergic to anything? (Please include medication, food, animal, and/or plant)

Type N/A if this does not apply

Is there anything else that you would like to let us know about you, your family, or your child?

Type N/A if this does not apply

I was assisted in preparing this form by: (Include full name and role)

Type N/A if this does not apply

Your information will be encrypted.