service requestmake a request with our team 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 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 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?* 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
