Before you begin, please have the information needed to complete this form. This may include basic details for the person needing services, parent or guardian contact information, school or daycare information, insurance details, medical information, weekly availability, and any documents you would like to upload.
If you are a provider making a referral, please also include your organization and contact information where requested.
Information you may need:
- Person needing services’ full name, date of birth, sex assigned at birth, and home address
- Reason services are being requested
- Parent or guardian contact information
- School or daycare details and schedule, if applicable
- Insurance information for all active plans
- Primary care provider or pediatrician contact information
- Current diagnoses, medical conditions, medications, and other services
- General weekly availability for services
- Any documents you would like to upload, such as medical or diagnostic records
Disclaimer: Submitting this form helps RCG continue reviewing the request for services. It does not guarantee enrollment, placement, the start of services, or a client-provider relationship.
Our standard program options are:
- Monday through Thursday, 10:00 AM to 2:00 PM
- Monday through Thursday, 3:30 PM to 7:00 PM
- Monday through Friday, 9:00 AM to 3:00 PM
While exceptions may be considered in limited circumstances, they are not the norm. Program schedules are generally determined based on clinical review, medical necessity, staffing availability, and insurance approval where applicable.
Services cannot begin until all review steps, intake requirements, clinical reviews, program availability checks, and any needed insurance authorizations have been completed.