Service Request 2

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Service Request 2

The Process for Becoming a Client

Learn how the process works end-to-end, starting with this form.

Request

Eligibility

Tour & Intake

Assessment

Curriculum

Treatment

Before you begin, please have the information needed to complete this form, including 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.

The person needing services’ full name, date of birth, sex assigned at birth, and home address
The reason they are seeking services
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 diagnosis records

Submitting this form is a request for services only and does not guarantee enrollment, the start of services, or a client-provider relationship. The RCG team will review the information submitted and may contact you for additional details or next steps. Services cannot begin until all intake requirements, clinical reviews, and any needed insurance authorizations are completed. Our center-based programs currently operate Monday through Thursday with two session options: 9:00 AM to 1:00 PM or 2:30 PM to 6:30 PM. Families should expect to attend the same session time each day, as session times cannot vary by day.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Getting Started

Who is completing this request?*

Name of person needing services*

Please enter the name exactly as it appears on the insurance card.

Date of birth of person needing services*

MM slash DD slash YYYY

Sex assigned at birth of person needing services*

Current address of person needing services*

Street Address City State ZIP Code

Is the person needing services a returning RCG client?*

Yes

Is the person needing services related to any current RCG staff member?*

Yes

How soon would the person needing services like to begin services?*

Why is the person needing services seeking services at RCG?*

How did you hear about us?*

Referral Source Information

Organization Name*

Name of person completing this request*

Prefix First Last

Job title / role*

Organization phone number*

Organization fax number*

Organization email*

Person Needing Service Details

Parent / guardian name*

Prefix First Last

Parent / guardian mobile phone*

Parent / guardian email*

Preferred contact method for parent / guardian

By selecting text message, you consent to receive text messages from RCG at the number provided.

Where does the person needing services typically spend daytime hours during the week?*

School (not homeschooled)

Daycare (organization, friend, or relative)

At home (including homeschooled)

Other

If other, please describe*

Name of school*

School address*

Days attending school*

Monday

Tuesday

Wednesday

Thursday

Friday

What times is the person needing services typically at school?*

Please describe school hours*

Name of daycare provider (organization, friend, or relative)*

Address of daycare provider (organization, friend, or relative)*

Days attending daycare*

Monday

Tuesday

Wednesday

Thursday

Friday

What times is the person needing services typically at daycare?*

Please describe daycare hours*

Does the person needing services participate in extracurricular activities?

What extracurricular activities does the person needing services participate in?*

Include the activity name, day(s), and usual time(s).

Insurance & Coverage Information

Does the person needing services currently have health insurance?*

How many health insurance plans does the person needing services currently have?*

Insurance 1 provider / plan name*

Insurance 1 ID number*

Who is the subscriber for insurance 1?*

Subscriber name for insurance 1*

Subscriber date of birth for insurance 1*

MM slash DD slash YYYY

Insurance 1 type

Insurance 2 provider / plan name*

Insurance 2 ID number*

Who is the subscriber for insurance 2?*

Subscriber name for insurance 2*

Subscriber date of birth for insurance 2*

MM slash DD slash YYYY

Insurance 2 type

Insurance 3 provider / plan name

Insurance 3 ID number

Who is the subscriber for insurance 3?

Subscriber name for insurance 3*

Subscriber date of birth for insurance 3*

MM slash DD slash YYYY

Insurance 3 type

Medical & Clinical Information

Has the person needing services been seen by a primary care provider or pediatrician within the last 12 months?

Primary care provider / pediatrician name

Primary care provider / pediatrician phone number

Does the person needing services currently have a medical diagnosis?

None

Autism Spectrum Disorder (ASD)

ADHD

Developmental Delay

Speech / Language Disorder

Intellectual Disability

Other

Other medical diagnosis*

Please separate each diagnosis with a comma.

What chronic medical conditions does the person needing services currently have?*

None

Allergies

Asthma

Chronic Pain

Diabetes

Feeding Difficulties

Gastrointestinal Concerns

Hearing Concerns

Heart Condition

High Blood Pressure

Mobility / Physical Limitations

Seizures

Sleep Difficulties

Vision Concerns

Other

Other chronic medical conditions*

Please separate each medical condition with a comma.

Upload supporting medical documents

Drop files here or

Max. file size: 32 MB.

Upload any diagnosis reports, medical records, or other supporting documents. You may upload multiple files.

Is the person needing services currently taking any prescription medications, including as-needed medications?*

Please list prescription medications*

Please separate each with a comma.

Is the person needing services currently taking any over-the-counter medications?*

Please list over-the-counter medications*

Please separate each with a comma.

Is the person needing services currently receiving any ongoing therapy or medical services from another provider?*

None

ABA Therapy

Speech Therapy

Occupational Therapy

Physical Therapy

Medical Treatment

Other

Other ongoing therapy or medical services*

Please separate each with a comma.

Provider / facility name for ABA therapy*

Location for ABA therapy*

Frequency for ABA therapy*

Other ABA frequency*

Provider / facility name for speech therapy*

Location for speech therapy*

Frequency for speech therapy*

Other speech frequency*

Provider / facility name for occupational therapy*

Location for occupational therapy*

Frequency for occupational therapy*

Other occupational frequency*

Provider / facility name for physical therapy*

Location for physical therapy*

Frequency for physical therapy*

Other physical therapy frequency*

Provider / facility name for medical treatment*

Location for medical treatment*

Frequency for medical treatment*

Other medical treatment frequency*

Provider / facility name for other services*

Location for other services*

Frequency for other services*

Other frequency for other services*

Schedule & Availability

Please tell us your availability for the following days.

Does the person needing services have reliable transportation to attend services, if needed?*

Which days is the person needing services available each week?

Monday

Tuesday

Wednesday

Thursday

Monday availability*

Tuesday availability*

Wednesday availability*

Thursday availability*

Social Enrichment Program

In the past 6 months, has your child displayed any of the following behaviors in group settings? (Check all that apply)*

Aggressive outbursts (hitting, kicking, biting)

Elopement (running away from structured activities or caregivers)

Difficulty following group instructions

None of the above

Challenging behaviors (Check any that have occurred in the last six months):*

Self-injury

Aggression towards peers

Aggression towards adults

Elopement (leaving area without permission/wandering off)

Property destruction

Tantrums (screaming/flopping to the floor – intensity or duration beyond what is typical for their age)

Foul language

Loud vocal stereotopy

Mouthing/licking/spitting

No problem behaviors of this kind

Other

Other challenging behaviors*

What are your primary goals for enrolling your child in this program? (Check up to three)*

Improving social interactions with peers

Enhancing communication skills

Learning self-care routines

Building confidence in group settings

Other

Elaborate other goals*

Describe your child’s interest in other kids/forming friendships.*

Can your child independently participate in small group activities without one-on-one assistance?*

What level of support does your child require in a group setting?*

How does your child typically communicate their needs?*

What best describes your child’s communication ability?*

What is your child’s current educational setting?*

Other educational setting?*

Identify 3-5 areas in which your child may currently benefit from supportive skill-building*

Communicating wants/needs, likes/dislikes

Expanding play & leisure skills

Following along in a group (directions, transitions)

Being flexible and tolerating changes/imperfections

Sportsmanship

Social conflict resolution (compromising, sharing, turn-taking)

Self-regulation & managing emotions

What is your child’s toileting independence level?*

My child's interests include:

Sports/physical activities

Art/music

Video games/technology

Animals/nature

Building/constructing (Legos, puzzles)

Other

Other child's interests*

My child does NOT enjoy*

Loud environments

Physical touch

Structured group activities

Trying new things

Other

Other dislikes*

Do you have additional questions or comments as we evaluate your request for services?

Service Request 2

The Process for Becoming a Client

Request

Eligibility

Tour & Intake

Assessment

Curriculum

Treatment

Getting Started

Referral Source Information

Person Needing Service Details

Insurance & Coverage Information

Medical & Clinical Information

Schedule & Availability

Social Enrichment Program

About RCG

Phone

Email