service requestmake a request with our team Parent / Caregiver Name Name of Person Needing Service Has your child received any services with RCG in the past?YesNo If yes, please provide us with the program and/or case supervisor and the discharge date of services if available. Services You Are Interested InABA Therapy - In HomeABA Therapy - Center BasedSchool PrepAfter SchoolLife PrepSpeech Therapy Are you related to any RCG members?YesNo Age of Person Needing Service Is the individual diagnosed with Autism?YesNo Address Line 1 Address Line 2 City State Phone Number Email Payment Method for ServicesCommercial InsuranceMedicaidPrivate Pay Submit Request
