EBS Clubhouse Forms

Please use the following forms to submit information to EBS Clubhouse.  You can either fill it out online or download and print the PDF and bring it to us.  If you choose to fill out a form online, please know that we take your security and privacy very seriously.  Online forms are hosted on EBS's secure, HIPAA-compliant server.  Please call or email us if you have any questions.

Intake

Telehealth Informed Consent


ABA / Behavior

ABA Intake Form &
Parent Handbook


Specialized Programs

Orofacial Myofunctional Client Intake


Literacy Program Patient Payment Responsibility


Additional Forms

Request an Evaluation

Informed Consent


Policies and Procedures


Patient
Rights


Email Medical Records Liability Release


Health Policy &
Emergency Protocol


Release of Medical Information


Patient Payment Responsibility


Cancellation, Illness, HIPAA & Insurance Change Policy


Photography &
Video Release


Caregiver Request to Photograph