Request Services

We will make every effort to accommodate your request for services based on your child’s needs, the professional expertise of our providers, and the availability of our staff. You can expect an acknowledgement of receipt from our intake coordinator within 1-2 business days. Please email officeadmin@lastingbehavioralsolutions.net if you have questions about this form.

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

Phone

Child's First and Last Name

Child's Date of Birth

(Month/Date/Year)

Do you currently have insurance?

Yes

Name of Insurance Carrier LBS in network with commercial carriers : Anthem, Magellan, Beacon and MHN.

Anthem BCBS

Magellan

MHN

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

Evaluation Pending

What services are you requesting

In Home ABA Therapy

Parent-Led ABA Therapy / Family Coaching

Social Group

Referred By

Pediatrician / Physician

Self Referral

School Referral

Speech or OT Referral

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

Your information will be encrypted.

Request Services

Intake Request Form

Intake Request Form