: 1.800.249.1266
Behavioral Health Works
Behavioral Health Works
Toggle navigation
How We Care
Individualized Outpatient Services
Ancillary Support Services
Funding for Services
Who We Are
Care Team
CARES Philosophy
BHW Advantage
Community
BHW Resources
BHW Channel
Contact
Contact Us
Enrollment
Partnership
Careers
Locations
Michigan
Ohio
Florida
New Jersey
Indiana
Texas
California
Colorado
Massachusetts
Maryland
Enrollment
Thank you for your interest in BHW services.
Please complete the form below and a
representative will contact you shortly.
Enrollment
Parent/Guardian Information:
Full Name
(Required)
Relationship to Child
(Required)
Email Address
(Required)
Phone Number
(Required)
Best Day/Time to Contact
Child Information
Child's Full Name
(Required)
Zip Code
(Required)
Confirmed Autism Diagnosis?
Yes
No
Preferred Service Location
In-Home
In-Center
Both
This field is hidden when viewing the form
Services Desired old
Speech
OT
ABA
Other
Services Desired
Speech
OT
ABA
Other
Other
This field is hidden when viewing the form
Availability for Services old
Monday
Tuesday
Wednesday
Thursday
Friday
Availability for Services
Monday
Tuesday
Wednesday
Thursday
Friday
Scheduling Availability and Barriers
Please specify your availability and any scheduling
barriers (e.g., school hours, therapy sessions). Include the specific hours
available for each day selected above.
Insurance Information
Insurance Provider Name
(Required)
Insurance ID #
(Required)
Secondary Insurance Name
Secondary Insurance ID
File Upload - Diagnostic Report
Drop files here or
Select files
Max. file size: 256 MB.
File Upload - Insurance Card, Front and Back
Drop files here or
Select files
Max. file size: 256 MB.
Enrollment Benefits
Full-service autism insurance verification and assistance
Free Parent Workshops and Training Opportunities
Behavioral Health Works
Behavioral Health Works