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Service Request
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
"
*
" indicates required fields
Simple Demographics
Parent / Guardian First Name
*
Parent / Guardian Last Name
*
Parent / Guardian Mobile Phone
*
Parent / Guardian Home Phone
Parent / Guardian Email
*
Location
Parent / Guardian Address
*
Street Address
Address Line 2
City
State
ZIP Code
Additional Details
How did you hear about us?
*
ABA Agency
Aveanna
Case Manager
Chesterfield Mental Health
Google Ads
Henrico Mental Health
Insurance Company
Ivy Rehab
Kindercare
Northstar
RBHA
RCG Employee
RCG Family
RCG vehicle
Sponsored Event/Fair
Spot On Therapy
UVA
VCU
Virginia Center for Autism (VCARDD)
Walk In
Other-physician/agency not listed
Name of Person Needing Service
*
DOB of Person Needing Service
*
MM slash DD slash YYYY
Which RCG Services are you interested in?
*
ABA Center Based Therapy
ABA In Home Therapy
Assistive Technology for Communication (AAC)
Life Prep Program (age 13 and up)
Occupational Therapy
Speech and Language Telehealth Services
Speech and Language Therapy in Person
Assessments and Evaluations
Social Enrichment Program
Is the person needing services a returning RCG client?
*
Yes
No
Are you related to any current RCG team member?
*
Yes
No
Is your child currently enrolled in school?
*
Yes Public
Yes Private
Yes Homeschool
Yes Homebound
Yes Online Only
Not at this time (graduated)
Not at this time (under age)
Is your child currently enrolled in daycare?
*
Yes Full Day
Yes Half Day
Not at this time
Case Manager
Does the person needing services have a case manager?
*
Yes
No
Case Manager's Name
*
Case Manager's Phone Number
*
Case Manager's Fax Number
Additional Details
Has the person needing service been diagnosed with autism?
*
Yes
No
Who was the diagnosing doctor of facility?
*
Who is the pediatrician or family/primary doctor for the person needing services?
*
Service Location Preference
*
RCG Midlothian Therapy Park Campus
RCG Henrico Campus
In Home
Hybrid (In Home & Midlothian Therapy Park Campus)
Hybrid (In Home & Henrico Campus)
What is the reason you are seeking services at RCG?
*
Schedule & Availability
Please tell us your availability for the following days.
Monday
*
9:00 AM - 12:00 PM
9:00 AM - 3:00 PM
9:00 AM - 6:00 PM
12:00 PM - 3:00 PM
12:00 PM - 6:00 PM
3:00 PM - 6:00 PM
Not Available
Tuesday
*
9:00 AM - 12:00 PM
9:00 AM - 3:00 PM
9:00 AM - 6:00 PM
12:00 PM - 3:00 PM
12:00 PM - 6:00 PM
3:00 PM - 6:00 PM
Not Available
Wednesday
*
9:00 AM - 12:00 PM
9:00 AM - 3:00 PM
9:00 AM - 6:00 PM
12:00 PM - 3:00 PM
12:00 PM - 6:00 PM
3:00 PM - 6:00 PM
Not Available
Thursday
*
9:00 AM - 12:00 PM
9:00 AM - 3:00 PM
9:00 AM - 6:00 PM
12:00 PM - 3:00 PM
12:00 PM - 6:00 PM
3:00 PM - 6:00 PM
Not Available
Friday
*
9:00 AM - 12:00 PM
9:00 AM - 3:00 PM
9:00 AM - 6:00 PM
12:00 PM - 3:00 PM
12:00 PM - 6:00 PM
3:00 PM - 6:00 PM
Not Available
Extracurricular Activities
Does the person needing service participates in extracurricular activities?
*
Yes
No
What is the frequency of these activities?
*
Once a week
Once every other week
Two or more sessions per week
Less than 2 times per month
What is the day(s) of these activities?
*
Multiple Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is the time(s) of these activities?
*
8 AM to 10 AM
10 AM to 12 PM
12 PM to 2 PM
2 PM to 4 PM
4 PM to 6 PM
Please elaborate on the Extracurricular Activities
*
Intensive Therapy
Does the person needing service currently receive intensive therapy?
*
Yes
No
What is the frequency of these therapies?
*
Once a week
Once every other week
Two or more sessions per week
Less than 2 times per month
What is the day(s) of these therapies?
*
Multiple Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is the time(s) of these therapies?
*
8 AM to 10 AM
10 AM to 12 PM
12 PM to 2 PM
2 PM to 4 PM
4 PM to 6 PM
Please elaborate on the Intensive Therapy
*
Intensive / Ongoing Medical Services
Does the person needing service currently receive intensive/ongoing medical services (ex. treatments, inpatient or overnight stays etc.)?
*
Yes
No
What is the frequency of these services?
*
Once a week
Once every other week
Two or more sessions per week
Less than 2 times per month
What is the day(s) of these services?
*
Multiple Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is the time(s) of these services?
*
8 AM to 10 AM
10 AM to 12 PM
12 PM to 2 PM
2 PM to 4 PM
4 PM to 6 PM
Please elaborate on the Intensive / Ongoing Medical Services
*
Payment / Insurance Information
Please provide your payment and insurance option(s):
*
Medicaid Only
Commercial Only
Commercial Primary/Medicaid Secondary
Commercial Primary/Commercial Secondary
FAPT
Waiver Funding
Private Pay
Tricare Only
Tricare Primary / Secondary (Medicaid or Commercial)
Not Applicable
If using medicaid for payment source, who is your medicaid provider?
Aetna Medicaid
Anthem Medicaid
BHSA Medicaid
Humana Medicaid
Molina Medicaid
Sentara Medicaid
UHC Medicaid
If using commercial insurance for payment source, who is your provider?
Aetna
Anthem
Beacon
Cigna
GEHA
Humana
Premera
UHC
UMR
Sentara
On rare occasions, some individuals might have a second commercial insurance. If this applies to you, please tell us the name of your second commercial insurance provider:
Aetna
Anthem
Beacon
Cigna
GEHA
Premera
UHC
UMR
Sentara
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, etc.)
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.
*
Enjoys being around other kids and actively engages
Observes peers but rarely engages
Prefers to play alone and does not seek peer interaction
Can your child independently participate in small group activities without one-on-one assistance?
*
Yes
Sometimes
No
What level of support does your child require in a group setting?
*
Requires consistent 1:1 support
May require 1:1 support depending on the activity
Does not require 1:1 support in small groups
How does your child typically communicate their needs?
*
Uses full sentences or short phrases
Uses single words, gestures, or pictures
Primarily nonverbal with limited communication
What best describes your child’s communication ability?
*
No formal mode of communication
Uses alternative communication (sign language, PECS, communication device)
Uses single words
Uses phrases
Speaks in sentences
What is your child’s current educational setting?
*
In-district self-contained classroom
In-district inclusion classroom
In-district general education
In-district other
Out-of-district specialized program
Homeschool
Other
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, etc.)
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?
*
100% independent
Needs support
Not toilet trained
My child's interests include:
*
Sports/physical activities
Art/music
Video games/technology
Animals/nature
Building/constructing (Legos, puzzles, etc.)
Other
Other child interest
*
My child does NOT enjoy
*
Loud environments
Physical touch
Structured group activities
Trying new things
Other
Other Dislikes
*
Will you have reliable transportation to attend sessions at RCG Park
*
Yes, we can consistently attend in all seasons
No, transportation may be an issue
This program requires a 12-18 month commitment with sessions Monday – Thursday from 4:00 PM – 6:00 PM at RCG Park. Can your child attend all sessions regularly?
*
Yes, we can commit to the full schedule
No, we have scheduling conflicts
Are you able to commit to this schedule during the summer months?
*
Yes, we can consistently attend in all seasons
No, transportation may be an issue
Final Questions or Comments
Do you have additional questions or comments as we evaluate your request for services?
Comments
This field is for validation purposes and should be left unchanged.
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