Request Services

Parent/Guardian's First and Last Name

Parent/Guardian's e-mail address

Parent/Guardian's Phone number

Parent/Guardian Home Address

Preferred Method of Contact

Email

Phone

Child's First and Last Name

Child's Date of Birth

(Month/Date/Year)

Do you currently have insurance? Please note that an Autism Diagnosis is required for insurance coverage. An Autism Diagnosis is not required with the Regional Center

Yes

No

Name of Insurance Carrier LBS in network with commercial carriers :

Anthem BCBS

Magellan

Regional Center of Orange County

Aetna

CalOptima / MediCal

Private Pay

Optum / United Healthcare

Other

Does your child have a diagnosis of Autism from a medical doctor? Please note that an Autism Diagnosis is required for most insurances

Yes

No

Evaluation Pending

What services are you requesting

Clinic Based Services

In Home ABA Therapy

Parent-Led ABA Therapy / Family Coaching

How did you hear about us?

Pediatrician / Physician

Self Referral

School Referral

Friend

Insurance

Google

None of the above

Reason For Referral

Does your child take any medications (Include frequency and Dosage below)

Upload the Front and Back of your insurance card

Add file

Please upload a file

Date of Birth for Policy Holder (if not under child)

Month/Date/Year

Request Services

Intake Request Form

Intake Request Form