Service Request

Simple Demographics

Parent or Guardian First Name*

Parent or Guardian Last Name*

Parent or Guardian Phone

Parent or Guardian Mobile*

Parent or Guardian Email*

Location

Parent or Guardian Street*

Parent or Guardian City*

Parent or Guardian State*

Parent or Guardian Zip*

Additional Details

Please note that once the date of birth field is filled in, the data will be white / transparent. It is not empty and your data will still be submitted!

How did you hear about us?*AnswerConnectClientConnect CardCustomer EventEmployee ReferralExternal ReferralFriendInternet SearchOtherPartnerPhysicianTrade ShowWalk InWebinarWebsite

Name of Person Needing Service*

DOB of Person Needing Service*

Which RCG Services are you interested in?*ABA Center Based TherapyABA In Home TherapyAssistive Technology for Communication (AAC)Life Prep Program (age 13 and up)Occupational TherapySpeech and Language Telehealth ServicesSpeech and Language Therapy in Person

Is the person needing services a returning RCG client?*YesNo

Are you related to any current RCG team member?*YesNo

Is your child currently enrolled in school?*Yes PublicYes PrivateYes HomeschoolYes HomeboundYes Online OnlyNot at this time (graduated)Not at this time (under age)

Is your child currently enrolled in daycare?*Yes Full DayYes Half DayNot at this time

Case Manager

Does the person needing services have a case manager?*YesNo

If yes, what is the case manager's name?

What is the case manager's phone number?

What is the case manager's fax number?

Additional Details

Has the person needing service been diagnosed with autism?*YesNo

If yes, 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 CampusRCG Henrico CampusIn HomeHybrid (In Home & Midlothian Therapy Park Campus)Hybrid (In Home & Henrico Campus)

Therapist Gender Preference*MaleFemaleNo Preference

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

Scheduling & Availability

Please tell us your availability for the following days.

What is your availability for Monday?*9:00 AM - 12:00 PM9:00 AM - 3:00 PM9:00 AM - 6:00 PM12:00 PM - 3:00 PM12:00 PM - 6:00 PM3:00 PM - 6:00 PMNot Available

What is your availability for Tuesday?*9:00 AM - 12:00 PM9:00 AM - 3:00 PM9:00 AM - 6:00 PM12:00 PM - 3:00 PM12:00 PM - 6:00 PM3:00 PM - 6:00 PMNot Available

What is your availability for Wednesday?*9:00 AM - 12:00 PM9:00 AM - 3:00 PM9:00 AM - 6:00 PM12:00 PM - 3:00 PM12:00 PM - 6:00 PM3:00 PM - 6:00 PMNot Available

What is your availability for Thursday?*9:00 AM - 12:00 PM9:00 AM - 3:00 PM9:00 AM - 6:00 PM12:00 PM - 3:00 PM12:00 PM - 6:00 PM3:00 PM - 6:00 PMNot Available

What is your availability for Friday?*9:00 AM - 12:00 PM9:00 AM - 3:00 PM9:00 AM - 6:00 PM12:00 PM - 3:00 PM12:00 PM - 6:00 PM3:00 PM - 6:00 PMNot Available

Extracurricular Activities

Does the person needing service participates in extracurricular activities?*YesNo

What is the frequency of these activities?Once a weekOnce every other weekTwo or more sessions per weekLess than 2 times per month

What is the day(s) of these activities?MondayTuesdayWednesdayThursdayFridaySaturdayMultiple Days

What is the time(s) of these activities?8 AM to 10 AM10 AM to 12 PM12 PM to 2 PM2 PM to 4 PM4 PM to 6 PM

Intensive Therapy

Does the person needing service currently receive intensive therapy?*YesNo

If yes, what is the frequency of these therapies?Once a weekOnce every other weekTwo or more sessions per weekLess than 2 times per month

What is the day(s) of these therapies?MondayTuesdayWednesdayThursdayFridaySaturdayMultiple Days

What is the time(s) of these therapies?8 AM to 10 AM10 AM to 12 PM12 PM to 2 PM2 PM to 4 PM4 PM to 6 PM

Intensive / Ongoing Medical Services

Does the person needing service currently receive intensive/ongoing medical services (ex. treatments, inpatient or overnight stays etc.)?*YesNo

If yes, what is the frequency of these services?Once a weekOnce every other weekTwo or more sessions per weekLess than 2 times per month

What is the day(s) of these therapies?MondayTuesdayWednesdayThursdayFridaySaturdayMultiple Days

What is the time(s) of these therapies?8 AM to 10 AM10 AM to 12 PM12 PM to 2 PM2 PM to 4 PM4 PM to 6 PM

Payment / Insurance Information

Please provide your payment and insurance option(s).*Medicaid OnlyCommercial OnlyCommercial Primary/Medicaid SecondaryCommercial Primary/Commercial SecondaryFAPTWaiver FundingPrivate PayTricare OnlyTricare Primary / Secondary (Medicaid or CommercialNot Applicable

If using medicaid for payment source, who is your medicaid provider?Aetna MedicaidAnthem MedicaidBHSA MedicaidMolina MedicaidOptima MedicaidUHC MedicaidVA Premier Medicaid

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

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:AetnaAnthemBeaconCignaGEHAOptimaPremeraUHCUMR

Final Questions or Comments

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

Submit Request