Service Request

Simple Demographics

Parent / Guardian First Name*

Parent / Guardian Last Name*

Parent / Guardian Mobile Phone*

Parent / Guardian Home Phone

Parent / Guardian Email*

Location

Additional Details

How did you hear about us?*

Name of Person Needing Service*

DOB of Person Needing Service*

Is your child currently enrolled in school?*

Is your child currently enrolled in daycare?*

Case Manager

Case Manager's Name*

Case Manager's Phone Number*

Case Manager's Fax Number

Additional Details

Who was the diagnosing doctor of facility?*

Who is the pediatrician or family/primary doctor for the person needing services?*

Service Location Preference*

What is the reason you are seeking services at RCG?*

Schedule & Availability

Please tell us your availability for the following days.

Monday*

Tuesday*

Wednesday*

Thursday*

Friday*

Extracurricular Activities

What is the frequency of these activities?*

What is the day(s) of these activities?*

Please elaborate on the Extracurricular Activities*

Intensive Therapy

What is the frequency of these therapies?*

What is the day(s) of these therapies?*

Please elaborate on the Intensive Therapy*

Intensive / Ongoing Medical Services

What is the frequency of these services?*

What is the day(s) of these services?*

Please elaborate on the Intensive / Ongoing Medical Services*

Payment / Insurance Information

Please provide your payment and insurance option(s):*

If using medicaid for payment source, who is your medicaid provider?

If using commercial insurance for payment source, who is your provider?

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:

Social Enrichment Program

Other Challenging Behaviors*

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?*

What is your child’s toileting independence level?*

Other child interest*

Other Dislikes*

Will you have reliable transportation to attend sessions at RCG Park*

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?*

Are you able to commit to this schedule during the summer months?*

Final Questions or Comments

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

Name

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

The Process for Becoming a Client

Request

Eligibility

Tour & Intake

Assessment

Curriculum

Treatment

Simple Demographics

Location

Additional Details

Case Manager

Additional Details

Schedule & Availability

Extracurricular Activities

Intensive Therapy

Intensive / Ongoing Medical Services

Payment / Insurance Information

Social Enrichment Program

Final Questions or Comments

About RCG

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